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https://upload.orthobullets.com/topic/5013/images/vancouver a radiograph.jpg
https://upload.orthobullets.com/topic/5013/images/eliptical modular.jpg
https://upload.orthobullets.com/topic/5013/images/jumbo cup.jpg
https://upload.orthobullets.com/topic/5013/images/intraopfx.jpg
https://upload.orthobullets.com/topic/5013/images/intraopfxfem.jpg
https://upload.orthobullets.com/topic/5013/images/cerclage wires.jpg
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
        • 0.4% of cemented arthroplasties
      • postoperative fractures
        • 0.1%
        • 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
        • 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
      • indications
        • intraoperative longitudinal calcar split   
    • 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
Image
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 provided 

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   
B2 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
Image
A Fracture in 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.

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 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 in elderly, low-demand patients

 

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Questions (43)
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(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. Intra-operative examination reveals the stem to be loose. What is the preferred treatment for this injury? Review Topic

QID: 3114
FIGURES:
1

Open reduction internal fixation with cables and proximal femoral locking plate

14%

(394/2841)

2

Open reduction internal fixation with allograft strut and multiple cables

5%

(151/2841)

3

Revision femoral component with proximal femoral replacement

1%

(25/2841)

4

Revision femoral component with long stem diaphyseal press-fit stem

78%

(2216/2841)

5

Revision femoral component with cemented stem

1%

(41/2841)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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(OBQ08.268) A nondisplaced periprosthetic small posterior wall acetabular fracture is noted intra-operatively during total hip arthroplasty. The acetabular component is stable and well-fixed after implantation of an ingrowth acetabular shell during intraoperative examination. Which of the following treatment options will best maintain motion and clinical function? Review Topic

QID: 654
1

ORIF of the posterior column and THA revision

3%

(57/2137)

2

Cage reconstruction of acetabular component

1%

(24/2137)

3

THA revision using a cemented acetabular component

1%

(16/2137)

4

Placement of a hip abductor brace and non-weight bearing in the affected limb

14%

(300/2137)

5

No change in treatment

81%

(1738/2137)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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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? Review Topic

QID: 1059
1

Continued insertion of the stem, cerclage wiring around the fracture site, and non-weight bearing x6 weeks

7%

(56/848)

2

Continued insertion of the stem, reduction of the hip, and non-weight bearing activity restrictions following surgery

2%

(17/848)

3

Removal of the stem, cerclage wiring around the fracture site, and re-insertion of a stem

88%

(749/848)

4

Removal of the stem and conversion to a cemented femoral stem

2%

(14/848)

5

Removal of the stem, open reduction internal fixation of the femur with planned delayed femoral stem insertion following fracture healing

1%

(6/848)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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? Review Topic

QID: 1337
FIGURES:
1

Revision of the acetabular component and ORIF of the femur with locking plates and cerclage wires

0%

(5/1547)

2

Revison of the femoral component, bypassing the fracture by two cortical diameters

8%

(128/1547)

3

Revision of the femoral component with impaction grafting and cerclage wires

2%

(27/1547)

4

Revision to a cemented component, bypassing the fracture by two cortical diameters

1%

(20/1547)

5

ORIF of the femur with locking plates and cerclage wires

88%

(1358/1547)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ13.136) Figure A shows the image of a 72-year-old male who sustained a fall from standing. Past medical history is significant for hypertension. He was a community ambulator without the use of a cane or walker prior to the fall. During the operation, he is noted to have a well-fixed acetabular component without significant wear of his polyethylene liner, but his femoral component is easily extractable. Which of the following correctly pairs his Vancouver classification and appropriate surgical intervention? Review Topic

QID: 4771
FIGURES:
1

Vancouver A, Revision of femoral component to cemented stem with fixation of the fracture

1%

(34/4190)

2

Vancouver B1, Revision of femoral component to cemented stem with fixation of the fracture

2%

(76/4190)

3

Vanvouver B1, Revision of femoral component to a long, porous-coated, cementless stem with fixation of the fracture

9%

(385/4190)

4

Vancouver B2, Fixation of the fracture with a plate and cerclage wires

2%

(99/4190)

5

Vancouver B2, Revision of femoral component to a long, porous-coated, cementless stem with fixation of the fracture

85%

(3571/4190)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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. The acetabular component is found to be well fixed in good position. In addition to using a new poly liner, what other procedure(s) is now indicated in this patient? Review Topic

QID: 2953
FIGURES:
1

Cemented femoral revision

7%

(127/1943)

2

Retention of current hardware and fixation using cerclage wires

1%

(15/1943)

3

Open reduction and internal fixation with a locking plate

2%

(46/1943)

4

Both uncemented femoral revision and revision of the acetabular shell

2%

(44/1943)

5

Uncemented femoral revision bypassing the distal deficiency by two cortices.

87%

(1700/1943)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 3202
FIGURES:
1

Traction for 3 weeks followed by 2 months of non-weight bearing mobilization

0%

(2/2294)

2

Open reduction and plate fixation with cable augmentation proximally

63%

(1435/2294)

3

Revision arthroplasty with a cementless long stem bypassing the fracture site by two cortical diameters

26%

(602/2294)

4

Revision arthroplasty with cemented femoral stem bypassing the fracture site by two cortical diameters

2%

(49/2294)

5

Revision arthroplasty with cementless long stem bypassing the fracture site by two cortical diameters and allograft strut augmentation

9%

(200/2294)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ12.217) An 82-year-old male sustains a ground level fall and sustains the injury shown in Figure A. Which of the following treatment methods is most appropriate for treating this injury? Review Topic

QID: 4577
FIGURES:
1

Closed reduction and functional bracing

0%

(6/3101)

2

Open reduction and fixation with a plate with screws and cerclage cables

86%

(2653/3101)

3

Open reduction and fixation with a cortical allograft strut and cerclage cables

11%

(349/3101)

4

Revision hip arthroplasty with bridging of the fracture with a plate with screws and cerclage cables

1%

(43/3101)

5

Total femoral replacement

1%

(34/3101)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ12.78) A 78-year-old female undergoes total hip arthroplasty through a minimally invasive surgical approach. During insertion of a metaphyseal fixation stem with a cementless press-fit technique, a crack in the calcar is identified. The stem is removed, two cable wires are passed around the calcar, and the same stem is reinserted. Which of the following statements is true? Review Topic

QID: 4438
1

The patient should be advised she is at greater risk of stem subsidence and early revision

19%

(772/4073)

2

Female sex is a risk factor for intraoperative calcar fracture

59%

(2384/4073)

3

A better outcome would be expected if a long-stem diaphyseal fixation stem had been inserted after recognition of the calcar fracture

14%

(586/4073)

4

Cementless press-fit technique is not a risk factor for intraoperative fracture

1%

(59/4073)

5

Minimally invasive surgical approach is not a risk factor for intraoperative fracture

6%

(251/4073)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(SBQ07HK.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? Review Topic

QID: 1647
FIGURES:
1

Revision total hip replacement with a proximally coated femoral stem

4%

(76/1833)

2

Open reduction, internal fixation with plate and cerclage wires

8%

(141/1833)

3

Proximal femoral replacement with megaprosthesis

85%

(1549/1833)

4

Impaction bone grafting

0%

(5/1833)

5

Cortical strut allograft with cerclage wiring

3%

(56/1833)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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? Review Topic

QID: 511
FIGURES:
1

Percutaneous locked plating

1%

(9/1561)

2

Open reduction internal fixation with a cable plate and allograft strut

4%

(64/1561)

3

Revision to a long, porous coated femoral stem with biplanar allograft struts

85%

(1320/1561)

4

Revision to a cemented revision femoral stem that bypasses the fracture site by 5 cm

9%

(148/1561)

5

Three months of non-weight bearing

1%

(12/1561)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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. An injury radiograph is provided in Figure A, while 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? Review Topic

QID: 366
FIGURES:
1

Traction for 6 weeks followed by slow return to weight bearing

0%

(1/961)

2

Open reduction and internal fixation

81%

(775/961)

3

Revision to a long, cementless femoral stem

13%

(122/961)

4

Revision to a long, cementless stem with strut allograft

3%

(30/961)

5

Revision to a long, cemented stem

2%

(24/961)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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? Review Topic

QID: 1010
FIGURES:
1

Toe-touch weightbearing

0%

(1/805)

2

Open reduction internal fixation with a cable plate

9%

(73/805)

3

Revision of the femur with a long, cementless stem

81%

(655/805)

4

Revision of the femur with a long, cemented stem

8%

(68/805)

5

Girdlestone resection arthroplasty

0%

(2/805)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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