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Updated: Nov 24 2024

THA Periprosthetic Fracture

Images
https://upload.orthobullets.com/topic/5013/images/b3.jpg
https://upload.orthobullets.com/topic/5013/images/vancouver b3.jpg
https://upload.orthobullets.com/topic/5013/images/vancouver a radiograph.jpg
https://upload.orthobullets.com/topic/5013/images/b1.jpg
https://upload.orthobullets.com/topic/5013/images/vancouver b2 radiograph.jpg
https://upload.orthobullets.com/topic/5013/images/vancouver c radiograph.jpg
https://upload.orthobullets.com/topic/5013/images/vancouver b3.jpg
  • summary
    • THA Periprosthetic Fractures are a complication of a total hip prosthesis with increasing incidence as a result of increased arthroplasty procedures and high-demands of elderly patients.
    • Diagnosis can be made with plain radiographs of the affected hip and ipsilateral femur.
    • Treatment may be nonoperative or operative based on location of fracture, implant stability and bone stock available. 
  • Epidemiology
    • Incidence
      • intraoperative fractures
        • 3.5% of primary uncemented hip replacements
        • 0.4% of cemented arthroplasties
      • postoperative fractures
        • 0.1%
        • most common at stem tip
  • Etiology
    • Classification
      • intraoperative fractures
        • femur
        • acetabulum
      • postoperative fractures
        • femur
        • acetabulum
    • 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
          • 0.2%
        • cementless acetabular components
          • 0.4%
      • mechanism
        • typically occurs during acetabular component impaction
      • risk factors
        • underreaming >2mm
        • elliptical 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
            • if posterior column is compromised, ORIF + revision is most stable construct
          • 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
          • 0.1-5%
        • 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
        • female gender
        • technical errors
        • cementless implants
        • osteoporosis
        • revision
        • minimally invasive techniques (controversial)
    • Presentation
      • change in resistance while inserting stem should raise suspicion for fracture
    • Classification
      • Vancouver classification (intraoperative)
        • considerations
          • location
          • pattern
          • stability of fracture
        • types
          • A - proximal metaphysis
          • B - diaphyseal
          • C - distal to stem tip (not amenable to insertion of longest revision stem)
        • subtypes
          • 1 - cortical perforation
          • 2 - nondisplaced crack
          • 3 - displaced unstable fracture pattern
    • Imaging
      • intraoperative radiographs are required when there is a concern for fracture
    • Treatment
      • stem removal, cabling, and reinsertion
      • 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
      • Vancouver Classification & Treatment - Intraoperative Periprosthetic Fracture
      • Type
      • Description 
      • Treatment
      • A1
      • Proximal metaphysis, cortical perforation
      • Bone graft alone (e.g. from acetabular reaming)
      • A2
      • Proximal metaphysis, nondisplaced crack
      • Cerclage wire before inserting stem (to prevent crack propagation)
      •  Ignore the fracture if fully porous coated stem is used (provided there is no distal propagation)
      • A3
      • Proximal metaphysis, displaced unstable fracture
      • Fully porous coated stem, or tapered fluted stem
      • Wires/cables/claw plate for isolated GT fractures
      • B1
      • Diaphyseal, cortical perforation (usually during cement removal)
      •  Fully porous coated stem (bypass by 2 cortical diameters) ± strut allograft
      • Diaphyseal, nondisplaced crack (from increased hoop stress during broaching or implant placement)
      • Cerclage wire (if implant stable)
      • Fully porous coated stem to bypass defect (if implant unstable) ± strut allograft
      •  PWB and observation (if detected postop)
      • B3
      • Diaphyseal, displaced unstable fracture (usually during hip dislocation, cement removal, stem insertion)
      • Fully porous coated stem to bypass defect ± strut allograft
      • C1
      • Distal to stem tip, cortical perforation (during cement removal)
      • Morcellized bone graft, fully porous coated stem to bypass defect, strut allograft
      • C2
      • Distal to stem tip, nondisplaced fracture
      • Cerclage wire, strut allograft
      • C3
      • Distal to stem tip, displaced unstable fracture
      • ORIF 
  • Postoperative Femur fracture
    • Introduction
      • incidence
        • 0.1-3% 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 (postoperative)
        • 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 - Postoperative Periprosthetic Fracture
      • Type
      • Description
      • Treatment
      • AG
      •  Fracture in greater trochanteric region.
      •  Commonly associated with osteolysis.
      •  AG (greater trochanter) fractures caused by retraction, broaching, actual implant insertion, previous hip screws.
      •  Often requires treatment that addresses the osteolysis.
      •  AG fractures with < 2cm displacement, treat nonoperatively with partial WB and allow fibrous union.
      •  AG fractures >2cm needs ORIF (loss of abductor function leads to instability) with trochanteric claw/cables
      • AL
      •  Fracture in lesser trochanteric region.
      • AL fractures are commonly treated non-operatively
      • 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, with a 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 it, with proximal bone that is poor quality or severely comminuted 
      •  Femoral component revision with proximal femoral allograft (APC) or proximal femoral replacement (PFR) 
      • 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
        • 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
      • 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 in elderly, low-demand patients
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