THA Periprosthetic Fracture

Author: Mark Karadsheh

Topic updated on 04/05/13 7:20pm

Introduction

Fractures around a total hip prosthesis increasing in incidence as a result of increased arthroplasty procedures and high-demands of elderly patients
Classification
- intraoperative fractures
  - femur
  - acetabulum
- postoperative fractures
  - femur
  - acetabulum
Epidemiology
- incidence
  - intraoperative fractures
    - 3.5% of primary uncemented hip replacements
    - .4% of cemented arthroplasties
  - postoperative fractures
    - .1%
    - most common at stem tip
Prevention
- preoperative templating reduces risk of intraoperative fractures
- adequate surgical exposure
- special care when using cementless prosthesis in poor bone (RA, osteoporosis)

Intraoperative Acetabular Fractures

Introduction
- incidence
  - cemented acetabular components
    - .2%
  - cementless acetabular components
    - .4%
- mechanism
  - typically occurs during acetabular component impaction
- risk factors
  - underreaming >2mm
  - eliptical modular cups
  - osteoporosis
  - cementless acetabular components
  - dysplasia
  - radiation
Evaluation
- must determine stability of implant
Treatment
- observation alone
  - indications
    - if evaluated intraoperatively and found to be stable
  - postoperative care
    - consider protected weight-bearing for 8-12 weeks
- acetabular revision with screws vs. ORIF
  - indications
    - if evaluated intraoperatively and found to be unstable
  - technique
    - addition of acetabular screws
    - may consider upgrading to "jumbo" cup
    - ORIF of acetabular fracture with revision of acetabular component
    - may add bone graft from reamings if patient has poor bone stock
  - postoperative care
    - consider protected weight-bearing for 8-12 weeks

Intraoperative Femur Fractures

Introduction
- incidence
  - primary THA
    - .1-5%
  - revision THA
    - 3-21%
- mechanism
  - proximal fractures
    - usually occur with bone preparation (ie aggressive rasping) and prosthetic insertion
    - may occur during implant insertion from dimension mismatch
  - middle-region fractures
    - usually occur when excessive force is used during surgical exposure or bone preparation
  - distal fractures
    - usually occur when tip of a straight-stem prosthesis impacting at femoral bow
- risk factors
  - impaction bone grafting
  - cementless implants
  - osteoporosis
  - revision
  - minimally invasive techniques (controversial)
Presentation
- change in resistance while inserting stem should raise suspicion for fracture
Imaging
- intraoperative radiographs are required when there is a concern for fracture
Treatment
- trochanteric fixation with wires, cables, or claw-plate
  - indications
    - intraoperative, proximal femur fractures
- removal of implant, insertion of longer stem prosthesis
  - indications
    - complete (two-part) fractures of middle region
  - technique
    - distal tip of stem must bypass distal extent of fracture by 2 cortical diameters
    - may use cortical allograft struts for added stability
- removal of implant, internal fixation with plate, reinsertion of prosthesis
  - indications
    - distal fractures that cannot be bypassed with a long-stemmed prosthesis

Postoperative Femur fracture

Introduction
- incidence
  - .1-3% for primary cementless total hip arthroplasties
- etiology
  - early postoperative fractures
    - cementless prosthesis tend to fracture in the first six months
    - likely caused by stress risers during reaming and broaching
    - wedge-fit tapered designs cause proximal fractures
    - cylindrical fully porous-coated stems tend to cause a distal split in the femoral shaft
  - late postoperative fractures
    - cemented prosthesis tend to fracture later (5 years out)
    - tend to fracture around the tip of the prosthesis or distal to it
- risk factors
  - poor bone quality
  - cementless prostheses
  - compromised bone stock
  - revision procedures
Classification
- Vancouver classification (see table below)
  - considerations
    - stability of prosthesis
    - location of fracture
    - quality of surrounding bone
  - pros
    - simple
    - validated
  - cons
    - often difficult to differentiate between B1 and B2 fractures based on radiographs alone

Vancouver Classification & Treatment
Type	Description	Treatment	Image
A	Fracture in trochanteric region	Commonly associated with osteolysis and often requires treatment that addresses the osteolysis. Consider ORIF in displaced fractures.
B1	Fracture around stem or just below it with a well fixed stem	ORIF using cerclage cables and locking plates
B2	Fracture around stem or just below it, loose stem, but good proximal bone stock	Revision of the femoral component to a long porous-coated cementless stems and fixation of the fracture fragment. Revision of the acetabular component if indicated.
B3	Fracture around stem or just below with proximal bone that is poor quality or severely comminuted	Femoral component revision with proximal femoral allograft or proximal femoral replacement
C	Fracture occurs well below the prosthesis	ORIF with plate - leave the hip and acetabular prosthesis alone

Presentation
- often result after low-energy trauma
Treatment
- nonoperative treatment with protected weight-bearing
  - indications
    - non-displaced periprosthetic fractures of greater trochanter
    - non-displaced fractures of lesser trochanter
  - technique
    - limiting abduction may decrease chances of displacement with greater trochanter fractures
- ORIF greater trochanter with wires, cables, or claw-plate
  - indications
    - displaced periprosthetic fractures of the greater trochanter
  - technique
    - if osteolysis is present, use cancellous allograft to fill defects
- ORIF femoral shaft with locking plate and cerclage wires
  - indications
    - Vancouver B1 fractures
    - Vancouver C fractures
  - technique
    - typically place cerclage wires/cables proximally and bicortical screws distal to stem
    - may use unicortical locking screws proximally
    - may add cortical strut allografts
- femoral component revision with long-stem prosthesis
  - indications
    - Vancouver B2 fractures
    - some Vancouver B3 fractures
- femoral component revision with proximal femoral allograft
  - indications
    - Vancouver B3 fractures in young patients
- femoral component revision with proximal femoral replacement
  - indications
    - Vancouver B3 fractures is elderly, low-demand patients

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Qbank (12 Questions)

TAG

(SBQ07.62) A 88-year-old female fell onto her right hip sustaining the fracture shown in Figure A. Past medical history is significant for mild dementia and moderate coronary artery disease. At baseline, she ambulates with a walker. There are concerns about her ability to maintain weight-bearing precautions following surgery. Which of the following is most appropriate for management of the femoral side? Topic

Review Topic

FIGURES: A

1. Non-operative management
2. Open reduction, internal fixation with plate and cerclage wires
3. Proximal femoral replacement with megaprosthesis
4. Impaction bone grafting
5. Cortical strut allograft with cerclage wiring

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph shows a Vancouver B3 periprosthetic fracture with poor proximal femoral bone stock. Given her age, co-morbidities, and dementia, the appropriate management of her condition would be a proximal femoral replacement with megaprosthesis. This can allow for immediate weight-bearing in the post-operative period.

Vancouver B3 periprosthetic fractures are fractures around or just below the tip of a loose stem with poor proximal femoral bone stock. Options for management of this fracture include a fully coated stem, a fluted tapered stem, a proximal femoral replacement with megaprosthesis, allograft-prosthesis composite, and impaction bone grafting. In elderly patients with co-morbidities and an inability to maintain the strict weight-bearing precautions that impaction bone grafting and allograft prosthetic replacements require, proximal femoral replacement with a megaprosthesis is the best option.

Duncan and Masri were the originators of the Vancouver classification system for periprosthetic fractures. Type A fractures are peritrochanteric, type B fracture are around the stem tip, and type C fractures are well below the stem tip.

Parvizi and Sim provide review the indications for proximal femoral replacements with megaprostheses. They conclude it is a reasonable option for elderly patients with massive proximal femoral bone loss. The most frequent complications are aseptic loosening and dislocation.

Klein and Parvizi et al. identified 23 patients who underwent proximal femoral replacement for a Vancouver type-B3 periprosthetic fracture. At a follow-up of 3 years, 22 of 23 patients were walking with minimal pain. The most frequent complications were persistent drainage (2), dislocation (2), refracture (1) and acetabular cage failure (1).

Figure A shows a Vancouver B3 periprosthetic fracture with loose stem and poor proximal bone stock. Illustration A shows an example of a proximal femoral replacement. Illustration B shows a radiograph of a proximal femoral replacement used for a failed total hip replacement with massive bone loss. Illustration C shows the Vancouver classification (A, B1, B2, B3, C)

Incorrect Answers:
Answer 1: Operative management is indicated to reduce pain and prevent complications associated with bedrest.
Answer 2: Given the degree of proximal femoral bone loss and loose stem, open reduction and internal fixation with a plate is not the best option.
Answer 4: Impaction bone grafting is an option for Vancouver B3 fractures, but are typically reserved for younger patients who have bone stock that needs to be restored.
Answer 5: Given the degree of proximal femoral bone loss and loose stem, cortical strut allograft with cerclage wiring is not the best option.

Illustrations: A

REFERENCES:

1. Duncan CP, Masri BA: Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293-304. PMID:7797866 (Link to Abstract)

2. Parvizi J, Sim FH: Proximal femoral replacements with megaprostheses. Clin Orthop 2004;420:169-175. PMID:15057093 (Link to Abstract)

3. Klein GR, Parvizi J, Rapuri V, et al: Proximal femoral replacement for treatment of periprosthetic fractures. J Bone Joint Surg Am 2005;87:1777-1781. PMID:16085618 (Link to Abstract)

Question Authors:

Mark Karadsheh MD, Jan Szatkowski MD, Michael Hughes MD,

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TAG

(OBQ10.26) In his first day home after undergoing a total hip arthroplasty a 65-year-old male falls down the stairs and sustains the fracture seen in Figure A and B. What is the preferred treatment for this injury? Topic

Review Topic

FIGURES: A

1. Open reduction internal fixation with cables and proximal femoral locking plate
2. Open reduction internal fixation with allograft strut and multiple cables
3. Revision femoral component with proximal femoral replacement
4. Revision femoral component with long stem diaphyseal press-fit stem
5. Revision femoral component with cemented stem

PREFERRED RESPONSE ▶

DISCUSSION: Figure A and B show a Vancouver B2 peri-prosthetic fracture. In Vancouver B2 periprosthetic femur fractures it is recommended that the fracture be stabilized with the use of an uncemented extensively porous coated femoral component. However, in order to increase the femoral strength similar to the contralateral side, the surgeon must bypass the most distal cortical deficiency by two cortices. Greidanus et al is an Instructional Course Lecture highlighting the various methods of treatment for peri-prosthetic fractures depending on bone stock, fracture classification, and available implants. Sledge et al described their technique in order to reconstruct the proximal femur as well as use a uncemented femoral stem to achieve good results.

REFERENCES:

1. Greidanus NV, Mitchell PA, Masri BA, Garbuz DS, Duncan CP. Principles of management and results of treating the fractured femur during and after total hip arthroplasty. Instr Course Lect. 2003;52:309-22. PMID:12690859 (Link to Abstract)

2. Masri BA, Davidson D, Duncan CP, Lewallen DG, Noiseux NO, Ranawat CS, et al. Total hip arthroplasty complications. In: Barrack RL, Booth RE Jr, Lonner JH, McCarthy JC, Mont MA, Rubash HE, eds. Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:475-503.

3. Sledge JB 3rd, Abiri A. An algorithm for the treatment of Vancouver type B2 periprosthetic proximal femoral fractures. J Arthroplasty. 2002 Oct;17(7):887-92. PMID:12375248 (Link to Abstract)

Question Authors:

Jan Szatkowski MD,

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(OBQ10.108) A 67-year-old man 6 years status post right total hip arthroplasty falls while walking his dog. He complains of pain and is unable to bear weight through the right leg. He denies any hip or thigh pain prior to this fall. A radiograph is provided in figure A. Which of the following is the most appropriate management? Topic

Review Topic

FIGURES: A

1. Traction for 3 weeks followed by 2 months of non-weight bearing mobilization
2. Open reduction and plate fixation with cable augmentation proximally
3. Revision arthroplasty with a cementless long stem bypassing the fracture site by two cortical diameters
4. Revision arthroplasty with cemented femoral stem bypassing the fracture site by two cortical diameters
5. Revision arthroplasty with cementless long stem bypassing the fracture site by two cortical diameters and allograft strut augmentation

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph demonstrates an oblique fracture of the femur at the tip of the stem. The fracture is stable within the proximal segment, a Vancouver B1 fracture. The radiograph is also notable for a stable vertically oriented acetabular component, but this does not affect the treatment plan. Illustration A depicts the Vancouver Classification of femoral periprosthetic hip fractures. B1 fractures are most appropriately treated with plate fixation. Choices 3 and 5 are appropriate treatments for B2 and B3 fractures, respectively.

Ricci et al reviewed 50 Vancouver B1 patients treated with indirect reduction and fixation utilizing a lateral plate without allograft strut augmentation. All patients went on to union. One was complicated by infection.

In an instructional course lecture, Ricci reviews the evaluation, classification, and management of femoral periprosthetic hip fractures.

Illustrations: A

REFERENCES:

1. Ricci WM, Bolhofner BR, Loftus T, Cox C, Mitchell S, Borrelli J Jr. Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant. Surgical Technique. J Bone Joint Surg Am. 2006 Sep;88 Suppl 1 Pt 2:275-82. PMID:16951099 (Link to Abstract)

2. Ricci WM, Haidukewych GJ. Periprosthetic femoral fractures. Instr Course Lect. 2009;58:105-15. PMID:19385524 (Link to Abstract)

3. Pike J, Davidson D, Garbuz D, Duncan CP, O'Brien PJ, Masri BA. Principles of treatment for periprosthetic femoral shaft fractures around well-fixed total hip arthroplasty. J Am Acad Orthop Surg. 2009 Nov;17(11):677-88. PMID:19880678 (Link to Abstract)

Question Authors:

John Badylak MD, Ben Taylor MD,

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(OBQ09.140) A previously healthy 68-year-old woman falls and sustains the fracture seen in Figure A. Her index procedure was approximately 10 years ago. The patient is taken to surgery, and the femoral stem is found to be loose, while the acetabulum seems well fixed. What procedure is now indicated in this patient? Topic

Review Topic

FIGURES: A

1. Cemented femoral revision
2. Retention of current hardware and fixation using cerclage wires
3. Open reduction and internal fixation with a locking plate
4. Both uncemented femoral revision and revision of the acetabular shell
5. Uncemented femoral revision bypassing the distal deficiency by two cortices.

PREFERRED RESPONSE ▶

DISCUSSION: This is a Vancouver B2 periprosthetic femur fracture as the fracture involves the tip of the stem and the stem is loose. In fracture patterns stabilization with an uncemented extensively porous coated femoral stem is recommended. However, in order to increase the femoral strength similar to the contralateral side, the surgeon must bypass the most distal cortical deficiency by two corticies.

O'Shea et al retrospectively found satisfactory results in patients with Vancouver B2 and B3 periprosthetic femur fractures treated with uncemented extensively porous coated femoral stems with good distal fixation.

Sledge et al described their technique in order to reconstruct the proximal femur as well as use an uncemented femoral stem to achieve good results.

Larson et al found an increase in femoral strength up to 84% of the contralateral side was achieved by bypassing the most distal deficiency by two cortical diameters.

Illustration A summarizes the Vancouver classification of periprosthetic femur fractures.

Illustrations: A

REFERENCES:

1. O'Shea K, Quinlan JF, Kutty S, Mulcahy D, Brady OH. The use of uncemented extensively porous-coated femoral components in the management of Vancouver B2 and B3 periprosthetic femoral fractures. J Bone Joint Surg Br. 2005 Dec;87(12):1617-21. PMID:16326872 (Link to Abstract)

2. Sledge JB 3rd, Abiri A. An algorithm for the treatment of Vancouver type B2 periprosthetic proximal femoral fractures. J Arthroplasty. 2002 Oct;17(7):887-92. PMID:12375248 (Link to Abstract)

3. Larson JE, Chao EY, Fitzgerald RH. Bypassing femoral cortical defects with cemented intramedullary stems. J Orthop Res. 1991 May;9(3):414-21. PMID:2010846 (Link to Abstract)

Question Authors:

Daniel Stahl MD, John Badylak MD, Michael Hughes MD,

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(OBQ08.125) A 65-year-old healthy patient fell 18 years after a total hip arthroplasty and sustained the fracture shown in Figure A. What is the most appropriate treatment? Topic

Review Topic

FIGURES: A

1. Percutaneous locked plating
2. Open reduction internal fixation with a cable plate and allograft strut
3. Revision to a long, porous coated femoral stem with biplanar allograft struts
4. Revision to a cemented revision femoral stem that bypasses the fracture site by 5 cm
5. Three months of non-weight bearing

PREFERRED RESPONSE ▶

DISCUSSION: The Vancouver classification of periprosthetic femur fractures is based on the fracture site, implant stability, and remaining bone stock. The patient in the question has a type B3 fracture. The cemented stem is loose and there is very poor remaining bone stock. He should be treated with a long, cementless revision stem with biplanar strut grafts. A tumor prosthesis or allograft-prosthesis composite would be alternate possibilities. Illustrations A and B are a diagram and table of the Vancouver classification of periprosthetic hip fractures.

Springer, et al. looked at the results and complications of revision total hip arthroplasty for the treatment of acute Vancouver type-B periprosthetic femoral fracture. In their series they treated these fractures in multiple ways, including cemented stems, uncemented stems, allograft-prosthetic composite, or tumor prosthesis. They concluded that the best results were with an uncemented, porous coated femoral stem, and the most common cause of revision was loosening.

Parvizi, et al. concluded that due to the poor bone quality and delayed healing of older patients & their periprosthetic fractures that it is imperative that a strong mechanical construct be achieved in the treatment of these fractures. They “advocate the use of numerous screws with purchase of at least ten cortices and reinforcement of fixation with biplanar strut allografts whenever possible. When a revision stem is used, we ensure that adequate diaphyseal fixation is obtained and the fracture is traversed by at least 5 to 8 cm.”

Illustrations: A

REFERENCES:

1. Springer BD, Berry DJ, Lewallen DG: Treatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am. 2003 Nov;85-A(11):2156-62. PMID:14630846 (Link to Abstract)

2. Parvizi J, Rapuri VR, Purtill JJ, Sharkey PF, Rothman RH, Hozack WJ. Treatment protocol for proximal femoral periprosthetic fractures. J Bone Joint Surg Am. 2004;86-A Suppl 2:8-16. PMID:15691103 (Link to Abstract)

Question Authors:

John Badylak MD, Patrick McCulloch MD, Michael Hughes MD,

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(OBQ08.268) A periprosthetic acetabular fractures is noted intra-operatively during total hip arthroplasty. The acetabular component is stable and well-fixed after implantation of an ingrowth acetabular shell. Which of the following treatment options will best maintain motion and clinical function? Topic

Review Topic

1. ORIF of the posterior column and THA revision
2. Cage reconstruction of acetabular component
3. THA revision using a cemented acetabular component
4. Placement of a hip abductor brace and non-weight bearing in the affected limb
5. No change in treatment

PREFERRED RESPONSE ▶

DISCUSSION: Acetabular fracture during total hip arthroplasty is a known complication that typically occurs during acetabular component impaction. If noticed intra-op, the stability of the component should be assessed by the surgeon to determine treatment. If the component is stable, no additional treatment is necessary. If the acetabular component is unstable, then it should be changed and/or supplemented with component screws until stability is obtained.

The referenced article by Haidukewych showed no need for acetabular fixation after fracture as long as the acetabular component was deemed stable. In their 7121 cases studied, they had a fracture rate of 0.4% and a high rate of fracture with elliptical monoblock cups. All fractures healed and the acetabular components achieved ingrowth without migration.

REFERENCES:

1. Haidukewych GJ, Jacofsky DJ, Hanssen AD, Lewallen DG. Intraoperative fractures of the acetabulum during primary total hip arthroplasty. J Bone Joint Surg Am. 2006 Sep;88(9):1952-6. PMID:16951110 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD, John Badylak MD, Ben Taylor MD,

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(OBQ06.180) A 78-year-old male falls at home four months following a right total hip arthroplasty. Right leg deformity, pain, and inability to bear weight are present on physical exam. He is neurovascularly intact. A radiograph is provided in Figure A. Radiographs taken immediately following the initial total hip arthroplasty are provided in Figures B and C. The patient denies any prodromal groin pain prior to his fall. Which of the following is the best treatment option? Topic

Review Topic

FIGURES: A

1. Traction for 6 weeks followed by slow return to weight bearing
2. Open reduction internal fixation with a cable plate
3. Revision to a long, cementless femoral stem
4. Revision to a long, cementless stem with strut allograft
5. Revision to a long, cemented stem

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation and radiograph are consistent with a Vancouver B1 periprosthetic femur fracture. The stem appears stable within the femur, and there is no evidence of subsidence with comparison to the initial post-THA radiographs. This fracture pattern is best treated with internal fixation. Illustrations A and B are radiographs of this patient following fixation with a cable plate. Illustrations C and D show bone healing at 2 years following the fracture. Duwelius et al report on 33 periprosthetic femur fractures. All fractures that demonstrated a stable stem at the time of surgery were treated with internal fixation, while those that were unstable were treated with a long, cementless revision femoral stem. At 2.5 years complications were minimal and the patients had regained their pre-fracture level of function. The review article by Kelley outlines the evaluation, classification, and treatment of periprosthetic femur fractures reinforcing the importance of stem stability within the femur. Periprosthetic fractures around a hemiarthroplasty should be treated with the same algorithm. However, if the patient had antecedent groin pain, then conversion to a total hip arthroplasty should be considered to prevent continued groin pain.

Illustrations: A

REFERENCES:

1. Duwelius PJ, Schmidt AH, Kyle RF, Talbott V, Ellis TJ, Butler JB. Aprospective, modernized treatment protocol for periprosthetic femur fractures.Orthop Clin North Am. 2004 Oct;35(4):485-92, PMID:15363923 (Link to Abstract)

2. Kelley SS. Periprosthetic Femoral Fractures. J Am Acad Orthop Surg. 1994May;2(3):164-172. PMID:10709005 (Link to Abstract)

Question Authors:

John Badylak MD, Ben Taylor MD, Dave Marcu MD,

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(OBQ05.124) An 82-year-old woman falls and sustains the fracture shown in figure A. She denies any history of dislocation or prodromal pain prior to her fall. What is the most appropriate treatment? Topic

Review Topic

FIGURES: A

1. Toe-touch weightbearing
2. Open reduction internal fixation with a cable plate
3. Revision of the femur with a long, cementless stem
4. Revision of the femur with a long, cemented stem
5. Girdlestone resection arthroplasty

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph demonstrates a periprosthetic femur fracture extending to the tip of the stem. The long spiral fracture is consistent with a loose implant. The bone stock is sufficient. Therefore, this fracture pattern would classify as a B2 using the Vancouver classification system. The Vancouver classification for periprosthetic femoral fractures is simple yet incorporates all the pertinent factors such a location, stem fixation, and bone stock. Type A is a trochanteric fracture- lesser or greater. These can be treated non-operatively usually and ORIF if symptomatic. Type B fractures are around or just below the stem and are subdivided into three types. Type B1 is a fracture with a well fixed stem. The treatment is cable plating or allograft struts or a combination of the two. Type B2 is a fracture with a loose stem with good bone stock. The treatment is a cementless porous coated long stem atleast two diameter length past the fracture site. Type B3 is a fracture with a loose stem and comminution. For younger patients, use cementless porous coated long stems with allograft struts. For older patients, consider a tumor prosthesis. Cement fixation is sometimes necessary Type C is a fracture well below the stem tip. These can be treated independently of the prosthesis.

Springer et al showed optimal outcomes with revision involving long extensively-coated femoral stems for Vancouver B fractures.

Masri et al review the classification and treatment of periprosthetic femur fractures.

REFERENCES:

1. Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res. 2004 Mar;(420):80-95. PMID:15057082 (Link to Abstract)

2. Springer BD, Berry DJ, Lewallen DG. Treatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am. 2003 Nov;85-A(11):2156-62. PMID:14630846 (Link to Abstract)

Question Authors:

John Badylak MD, Patrick McCulloch MD, Derek Moore,

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(OBQ05.173) During insertion of a cementless femoral stem, a nondisplaced fracture is noticed along the femoral calcar. Which of the following is the most appropriate next step in surgical management? Topic

Review Topic

1. Trial reduction of the stem in place without further insertion of the stem
2. Continued insertion of the stem, reduction of the hip, and non-weight bearing activity restrictions following surgery
3. Removal of the stem, cerclage wiring around the fracture site, and insertion of a stem that bypasses the distal extent of the fracture by 2 cortical diameters of the femur
4. Removal of the stem and conversion to a cemented femoral stem
5. Removal of the stem, open reduction internal fixation of the stem with planned delayed femoral stem insertion following fracture healing

PREFERRED RESPONSE ▶

DISCUSSION: Appropriate care of an intraoperative fracture during total hip arthroplasty requires removal of the stem to adequately evaluate the fracture. The fracture should then be stabilized with cerclage wiring, and a long stem should be inserted to ensure stability of the stem in the post-operative period. Tsiridis et al review the identification, classification, and management of intra-operative and post-operative periprosthetic hip fractures. Postoperative fractures around stable components may be treated with open surgical fixation. All intra-operative fractures should be considered inherently unstable, and should be treated with a long stem that bypasses the femoral fracture by two diameters of the cortical bone and cerclage wiring.

REFERENCES:

1. Tsiridis E, Haddad FS, Gie GA. The management of periprosthetic femoral fractures around hip replacements. Injury. 2003 Feb;34(2):95-105. PMID:12565015 (Link to Abstract)

Question Authors:

John Badylak MD,

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(OBQ04.232) A 67-year-old man who underwent total hip arthroplasty (THA) 4 years ago fell on to his right hip. His pre-injury right hip film is seen in Figure A while films of his current injury are seen in Figures B and C. Prior to the fall he had no thigh or hip pain. His ESR and CRP are within normal limits. During intraoperative assessment, the acetabular and femoral stems are found to be well fixed. What is the next best course of action? Topic

Review Topic

FIGURES: A

1. Revision of the acetabular component and ORIF of the femur with locking plates and cerclage wires
2. Revison of the femoral component, bypassing the fracture by two cortical diameters
3. Revision of the femoral component with impaction grafting and cerclage wires
4. Revision to a cemented component, bypassing the fracture by two cortical diameters
5. ORIF of the femur with locking plates and cerclage wires

PREFERRED RESPONSE ▶

DISCUSSION: The patient in the scenario has well-fixed femoral and acetabular components with a fracture at the level of the implant extending to tip. This corresponds to a Vancouver B1 fracture. Treatment for B1 fractures is open or closed reduction, followed by internal fixation with locking plates. See Illustrations A, B and C. The Vancouver Classification is seen in Illustration D and fully described in the Review topic section.

Pike et al review the current trends in treating B1 fractures including locking plates with strut allografts, minimally invasive plate osteosynthesis (MIPO) and locking plates spanning femoral THA and TKA stems in selected patients. The authors conclude that no studies currently provide evidence establishing one technique over the other and recommend treatment on a case by case basis. They provide an algorithm to aid in decision making. See Illustration E.

Illustrations: A

REFERENCES:

1. Pike J, Davidson D, Garbuz D, Duncan CP, O'Brien PJ, Masri BA. Principles of treatment for periprosthetic femoral shaft fractures around well-fixed total hip arthroplasty. J Am Acad Orthop Surg. 2009 Nov;17(11):677-88 PMID:19880678 (Link to Abstract)

Question Authors:

Terrill Julien MD, Jan Szatkowski MD, Dave Marcu MD,

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Cases

http://upload.orthobullets.com/cases/1126/periprosthetic acetabular fx 1g.jpg

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Periprosthetic Acetabular Fracture (THA) (C1126)

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Evidence & References Show References

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

O'Shea K, Quinlan JF, Kutty S, Mulcahy D, Brady OH. The use of uncemented extensively porous-coated femoral components in the management of Vancouver B2 and B3 periprosthetic femoral fractures. J Bone Joint Surg Br. 2005 Dec;87(12):1617-21. PMID:16326872 (Link to Abstract)
Larson JE, Chao EY, Fitzgerald RH. Bypassing femoral cortical defects with cemented intramedullary stems. J Orthop Res. 1991 May;9(3):414-21. PMID:2010846 (Link to Abstract)
Haidukewych GJ, Jacofsky DJ, Hanssen AD, Lewallen DG. Intraoperative fractures of the acetabulum during primary total hip arthroplasty. J Bone Joint Surg Am. 2006 Sep;88(9):1952-6. PMID:16951110 (Link to Abstract)

Level of Evidence 4 (Case Series)

Klein GR, Parvizi J, Rapuri V, et al: Proximal femoral replacement for treatment of periprosthetic fractures. J Bone Joint Surg Am 2005;87:1777-1781. PMID:16085618 (Link to Abstract)
Ricci WM, Bolhofner BR, Loftus T, Cox C, Mitchell S, Borrelli J Jr. Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant. Surgical Technique. J Bone Joint Surg Am. 2006 Sep;88 Suppl 1 Pt 2:275-82. PMID:16951099 (Link to Abstract)
Sledge JB 3rd, Abiri A. An algorithm for the treatment of Vancouver type B2 periprosthetic proximal femoral fractures. J Arthroplasty. 2002 Oct;17(7):887-92. PMID:12375248 (Link to Abstract)
Duwelius PJ, Schmidt AH, Kyle RF, Talbott V, Ellis TJ, Butler JB. Aprospective, modernized treatment protocol for periprosthetic femur fractures.Orthop Clin North Am. 2004 Oct;35(4):485-92, PMID:15363923 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Duncan CP, Masri BA: Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293-304. PMID:7797866 (Link to Abstract)
Parvizi J, Sim FH: Proximal femoral replacements with megaprostheses. Clin Orthop 2004;420:169-175. PMID:15057093 (Link to Abstract)
Greidanus NV, Mitchell PA, Masri BA, Garbuz DS, Duncan CP. Principles of management and results of treating the fractured femur during and after total hip arthroplasty. Instr Course Lect. 2003;52:309-22. PMID:12690859 (Link to Abstract)
Ricci WM, Haidukewych GJ. Periprosthetic femoral fractures. Instr Course Lect. 2009;58:105-15. PMID:19385524 (Link to Abstract)
Pike J, Davidson D, Garbuz D, Duncan CP, O'Brien PJ, Masri BA. Principles of treatment for periprosthetic femoral shaft fractures around well-fixed total hip arthroplasty. J Am Acad Orthop Surg. 2009 Nov;17(11):677-88. PMID:19880678 (Link to Abstract)
Kelley SS. Periprosthetic Femoral Fractures. J Am Acad Orthop Surg. 1994May;2(3):164-172. PMID:10709005 (Link to Abstract)
Tsiridis E, Haddad FS, Gie GA. The management of periprosthetic femoral fractures around hip replacements. Injury. 2003 Feb;34(2):95-105. PMID:12565015 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Masri BA, Davidson D, Duncan CP, Lewallen DG, Noiseux NO, Ranawat CS, et al. Total hip arthroplasty complications. In: Barrack RL, Booth RE Jr, Lonner JH, McCarthy JC, Mont MA, Rubash HE, eds. Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:475-503.
Sledge JB 3rd, Abiri A. An algorithm for the treatment of Vancouver type B2 periprosthetic proximal femoral fractures. J Arthroplasty. 2002 Oct;17(7):887-92. PMID:12375248 (Link to Abstract)
Springer BD, Berry DJ, Lewallen DG: Treatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am. 2003 Nov;85-A(11):2156-62. PMID:14630846 (Link to Abstract)
Parvizi J, Rapuri VR, Purtill JJ, Sharkey PF, Rothman RH, Hozack WJ. Treatment protocol for proximal femoral periprosthetic fractures. J Bone Joint Surg Am. 2004;86-A Suppl 2:8-16. PMID:15691103 (Link to Abstract)
Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res. 2004 Mar;(420):80-95. PMID:15057082 (Link to Abstract)
Springer BD, Berry DJ, Lewallen DG. Treatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am. 2003 Nov;85-A(11):2156-62. PMID:14630846 (Link to Abstract)
Pike J, Davidson D, Garbuz D, Duncan CP, O'Brien PJ, Masri BA. Principles of treatment for periprosthetic femoral shaft fractures around well-fixed total hip arthroplasty. J Am Acad Orthop Surg. 2009 Nov;17(11):677-88 PMID:19880678 (Link to Abstract)
Berry DJ: Management of periprosthetic fractures: The hip. J Arthroplasty 2002;17:11-13 PMID:12068395 (Link to Abstract)
Ries MD: Periprosthetic fractures: Early and late. Orthopedics 1997;20:798-800 PMID:9306457 (Link to Abstract)

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THA Periprosthetic Fracture

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