Posted: Sep 5 2021 #(C101783)

THA Periprosthetic Femur Fracture in 89F

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HPI

An 89-year-old female presents to the ED after a ground-level fall. The patient has had a history of several falls in the last month. She currently lives in an assisted living facility. After the most recent fall, the patient has been unable to bear weight and complains of severe left thigh and leg pain. The patient occasionally ambulates but spends most of her day in a wheelchair. She denies pain in any other extremities. Prior to the fall the patient and no symptoms related to her THA. She had no groin pain and reported she was very satisfied with her THA prior to the fall. There is no record of serum metal ion (cobalt and chromium) levels.

PMH

PMH: Alzheimer's disease, Hypertension, Osteoporosis, Polyneuropathy, Vitamin D deficiency PSH: THA (metal-on-metal)

The patient is awake, alert and answers questions appropriately. Focused physical examination of the left lower extremity reveals deformity and swelling of the left thigh without skin tenting or open wounds. There is tenderness to palpation over mid and proximal thigh. She is neurovascularly intact.

Poll

1 of 13

In addition to standard AP and LAT Xrays of the femur, would you obtain any further imaging to guide your treatment?

No - AP and LAT Xrays are sufficient

64%

(368/571)

Yes - additional Xrays (aXR) (includes post reduction, contralateral, other)

(37/571)

Yes - CT (includes CTA, 3D recon)

21%

(120/571)

Yes - MRI (includes MRA, MARS)

(5/571)

Yes - aXR + CT

(25/571)

Yes - aXR + MRI

(1/571)

Yes - CT + MRI

(6/571)

Yes - aXR + MRI + CT

(3/571)

Outside my area of expertise - best if I don't vote

(6/571)

Based on the injury xrays provided, do you think the femoral component is stable/fixed or loose?

Stable/Fixed

83%

(471/565)

Loose

(54/565)

Unable to tell based on radiographs alone

(36/565)

Outside my area of expertise - best if I don't vote

(4/565)

Would you obtain metal ion (cobalt, chromium) serum levels, and would they change your management if elevated?

No, I would not obtain metal ion serum levels

73%

(408/558)

Yes, I would obtain, but results would Not change my management

15%

(85/558)

Yes, I would obtain, and results Would Change my management

10%

(56/558)

Outside my area of expertise - best if I don't vote

(9/558)

If you choose to use the Vancouver Classification System, How would you classify this fx?

I would not classify it with the Vancouver System - it does not help me

11%

(60/532)

A (G)

(4/532)

A (L)

(8/532)

32%

(174/532)

15%

(81/532)

(38/532)

21%

(112/532)

(19/532)

(12/532)

Outside my area of expertise - best if I don't vote

(24/532)

How would you manage this injury?

Nonoperative

(3/543)

Operative

99%

(540/543)

Outside my area of expertise - best if I don't vote

(0/543)

If you choose Operative Management, what treatment would you choose?

I would not choose Operative Management

(0/551)

Open Reduction Internal Fixation (ORIF) Alone

82%

(456/551)

Revision Arthroplasty (rTHA) Alone

(18/551)

Intramedullary Nail Fixation (IMN) Alone

(4/551)

External Fixation (ExFix) Alone

(4/551)

rTHA + ORIF

(51/551)

rTHA + IMN

(5/551)

rTHA + ExFix

(2/551)

ORIF + IMN

(2/551)

Other Combination

(3/551)

Outside of my area of expertise - best if I don't vote

(6/551)

If you choose Revision Arthroplasty, which component(s) are you going to revise?

I would not choose Revision Arthroplasty

67%

(355/525)

Acetabulum Alone

(9/525)

Femur Alone

24%

(128/525)

Acetabulum + Femur

(28/525)

Outside my area of expertise - best if I don't vote

(5/525)

If you choose ORIF Alone, what fixation construct would you use?

I would Not choose ORIF Alone

(14/534)

Plate(s), includes plate screws (Plates) Alone

(38/534)

Cerclage Cable(s) (Cable) Alone

(4/534)

Standalone or Lag Screw(s) (Screws) Alone

(0/534)

Plate(s) + Cable(s)

20%

(110/534)

Plate(s) + Screw(s)

(27/534)

Cable(s) + Screw(s)

(4/534)

Plate(s) + Cable(s) + Screw(s)

62%

(333/534)

Outside my area of expertise - best if I don't vote

(4/534)

If you choose ORIF Alone with Plate(s) + Cable(s), what positioning and surgical approach would you use?

I would Not choose ORIF Alone with Plate(s) + Cable(s)

(8/513)

Supine, subvastus approach to femur

19%

(99/513)

Supine, vastus splitting approach to femur

13%

(68/513)

Lateral, subvastus approach to femur

42%

(216/513)

Lateral, vastus splitting approach to femur

21%

(111/513)

Other

(1/513)

Outside my area of expertise - best if I don't vote

(10/513)

If you choose ORIF Alone with Plate(s) + Cable(s), how would you achieve proximal fixation?

I would not choose ORIF Alone with Plate(s) + Cable(s)

(16/492)

Cerclage Cable fixation alone

(28/492)

Unicortical non-locking screw(s) +/- cerclage Cable(s)

12%

(62/492)

Unicortical locking screw(s) +/- cerclage Cable(s)

51%

(253/492)

Bicortical non-locking screw(s) +/- cerclage Cable(s)

(34/492)

Bicortical locking screw(s) +/- cerclage Cable(s)

18%

(93/492)

Other

(2/492)

Outside my area of expertise - best if I don't vote

(4/492)

If you choose ORIF Alone with Plate(s) + Cable(s), and obtained the construct shown, what initial post-operative weight-bearing status would you assign the patient?

I would not choose ORIF Alone with Plate(s) + Cable(s)

(12/447)

Non-weight bearing (NWB)

39%

(176/447)

Touch-down weight bearing (TDWB)

29%

(134/447)

Partial weight bearing (PWB, < 25-50%)

11%

(53/447)

Weight-bearing as tolerated (WBAT)

15%

(69/447)

Outside my area of expertise - best if I don't vote

(3/447)

If you choose ORIF Alone with Plate(s) + Cable(s), and obtained the construct shown, and would make the patient NWB, what DVT prophylaxis would you prescribe?

I would not choose ORIF Only with Plate(s) with screws + Cerclage Cable(s) and make the patient NWB

(15/447)

Aspirin (any dose)

20%

(90/447)

Low molecular weight heparin (Lovenox)

60%

(270/447)

Heparin transitioned to Coumadin

(4/447)

Xa inhibitors (Xarelto etc.)

12%

(58/447)

Other pharmacological medication

(6/447)

Outside my area of expertise - best if I don't vote

(4/447)

If you choose ORIF Alone with Plate(s) + Cable(s) and obtained the construct shown, when would you allow for FULL weight-bearing?

I would not choose ORIF Alone with Plate(s) + Cable(s)

(11/455)

< 2 weeks

(27/455)

3-4 weeks

(12/455)

5-6 weeks

22%

(104/455)

7-8 weeks

24%

(111/455)

9-10 weeks

(35/455)

11-12 weeks

12%

(59/455)

> 12 weeks

10%

(47/455)

Until Evidence of Union on Xrays

(44/455)

Until Evidence of Union on CT Scan

(2/455)

Outside my area of expertise - best if I don't vote

(3/455)

In addition to standard AP and LAT Xrays of the femur, would you obtain any further imaging to guide your treatment?

No - AP and LAT Xrays are sufficient

Based on the injury xrays provided, do you think the femoral component is stable/fixed or loose?

Stable/Fixed

Would you obtain metal ion (cobalt, chromium) serum levels, and would they change your management if elevated?

Yes, I would obtain, but results would Not change my management

If you choose to use the Vancouver Classification System, How would you classify this fx?

How would you manage this injury?

Operative

If you choose Operative Management, what treatment would you choose?

Open Reduction Internal Fixation (ORIF) Alone

If you choose Revision Arthroplasty, which component(s) are you going to revise?

I would not choose Revision Arthroplasty

If you choose ORIF Alone, what fixation construct would you use?

Plate(s) + Cable(s) + Screw(s)

If you choose ORIF Alone with Plate(s) + Cable(s), what positioning and surgical approach would you use?

Supine, subvastus approach to femur

If you choose ORIF Alone with Plate(s) + Cable(s), how would you achieve proximal fixation?

Bicortical locking screw(s) +/- cerclage Cable(s)

If you choose ORIF Alone with Plate(s) + Cable(s), and obtained the construct shown, what initial post-operative weight-bearing status would you assign the patient?

Non-weight bearing (NWB)

If you choose ORIF Alone with Plate(s) + Cable(s), and obtained the construct shown, and would make the patient NWB, what DVT prophylaxis would you prescribe?

Aspirin (any dose)

If you choose ORIF Alone with Plate(s) + Cable(s) and obtained the construct shown, when would you allow for FULL weight-bearing?

9-10 weeks

Post-procedure P1

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