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)
fully porous coated stem, or tapered fluted stem provided
wires/cables/claw plate for isolated GT fractures
cerclage wire (if implant stable)
fully porous coated stem to bypass defect (if implant unstable) ± strut allograft
PWB and observation (if detected postop)
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.
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An 85-year-old woman sustains a ground level fall. Her THA was done 25 years ago. She was previously ambulatory but with a significant limp. With regard to the femur specifically, what is the Vancouver classification and preferred treatment option?
Vancouver C, revision to proximal femoral replacement
Vancouver B1, ORIF with impaction grafting
Vancouver AG, ORIF
Vancouver B3, revision to proximal femoral replacement
Vancouver B2, ORIF with femoral strut allograft augmentation
Select Answer to see Preferred Response
Which of the following fractures would most likely require revision arthroplasty with a long-stemmed, uncemented prosthesis?
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?
Vancouver A, Revision of femoral component to cemented stem with fixation of the fracture
Vancouver B1, Revision of femoral component to cemented stem with fixation of the fracture
Vanvouver B1, Revision of femoral component to a long, porous-coated, cementless stem with fixation of the fracture
Vancouver B2, Fixation of the fracture with a plate and cerclage wires
Vancouver B2, Revision of femoral component to a long, porous-coated, cementless stem with fixation of the fracture
A healthy, active 72-year-old man tripped and fell, landing on his left hip 10 weeks after an uncomplicated left primary uncemented total hip replacement. A radiograph taken 6 weeks after surgery and before the fall is shown in Figure 10a. A radiograph taken after the fall is shown in Figure 10b. He was unable to bear weight and was brought to the emergency department. Examination revealed a slightly shortened left lower extremity and some mild ecchymosis just distal to the left greater trochanteric region, but his skin was intact without abrasions or lacerations. What is the most appropriate treatment?
Open reduction and cerclage fixation of the fracture
Open reduction and revision of the femoral implant to a long cemented stem
Open reduction and revision of the femoral implant to a long fluted and tapered uncemented stem
Application of balanced traction and surgery after the ecchymosis has resolved
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?
Closed reduction and functional bracing
Open reduction and fixation with a plate with screws and cerclage cables
Open reduction and fixation with a cortical allograft strut and cerclage cables
Revision hip arthroplasty with bridging of the fracture with a plate with screws and cerclage cables
Total femoral replacement
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?
The patient should be advised she is at greater risk of stem subsidence and early revision
Female sex is a risk factor for intraoperative calcar fracture
A better outcome would be expected if a long-stem diaphyseal fixation stem had been inserted after recognition of the calcar fracture
Cementless press-fit technique is not a risk factor for intraoperative fracture
Minimally invasive surgical approach is not a risk factor for intraoperative fracture
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?
Open reduction internal fixation with cables and proximal femoral locking plate
Open reduction internal fixation with allograft strut and multiple cables
Revision femoral component with proximal femoral replacement
Revision femoral component with long stem diaphyseal press-fit stem
Revision femoral component with cemented stem
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?
Traction for 3 weeks followed by 2 months of non-weight bearing mobilization
Open reduction and plate fixation with cable augmentation proximally
Revision arthroplasty with a cementless long stem bypassing the fracture site by two cortical diameters
Revision arthroplasty with cemented femoral stem bypassing the fracture site by two cortical diameters
Revision arthroplasty with cementless long stem bypassing the fracture site by two cortical diameters and allograft strut augmentation
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?
Cemented femoral revision
Retention of current hardware and fixation using cerclage wires
Open reduction and internal fixation with a locking plate
Both uncemented femoral revision and revision of the acetabular shell
Uncemented femoral revision bypassing the distal deficiency by two cortices.
A 65-year-old healthy patient fell 18 years after a total hip arthroplasty and sustained the fracture shown in Figure A. Which of the following would be the most appropriate treatment?
Percutaneous locked plating
Open reduction internal fixation with a cable plate and allograft strut
Revision to a long femoral stem with allograft bone
Revision to a cemented revision femoral stem that bypasses the fracture site by 5 cm
Three months of non-weight bearing
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?
ORIF of the posterior column and THA revision
Cage reconstruction of acetabular component
THA revision using a cemented acetabular component
Placement of a hip abductor brace and non-weight bearing in the affected limb
No change in treatment
During impaction of a cementless acetabular component, the posterior column was fractured and found to be displaced. Which of the following is considered the most appropriate surgical option?
Exchange of the cementless cup to a larger component
Retention of the component and bone grafting of the fracture
Retention of the component and postoperative weight protection until the posterior column heals
Removal of the cup, fixation of the posterior column, and application of an antiprotrusio cage
Removal of the cup and cementing of an all-polyethylene liner
In the radiograph shown in Figure 42, the fracture pattern around this well-fixed stem is classified as Vancouver type
A 53-year-old patient is seen in the emergency department after sustaining a fall onto her left hip. A current radiograph is shown in Figure 40. What is the best treatment option?
Bed rest and non-weight-bearing for 6 to 8 weeks
Component retention and open reduction and internal fixation
Proximal femoral replacement prosthesis
Revision arthroplasty with a long cemented stem
Revision arthroplasty with a long porous-coated cylindrical stem
Figure 37 reveals a periprosthetic fracture around a cemented femoral stem in an 81-year-old patient with Paget’s disease and mild coagulopathy. What is the most appropriate reconstructive management on the femoral side?
Open reduction and internal fixation
Proximally coated femoral stem
Allograft prosthetic composite (APC)
Proximal femoral replacement (PFR)
Figure 36 shows the radiograph of a patient who has hip pain and is unable to ambulate. What is the most appropriate management for this patient?
Protected weight bearing
Revision total hip arthroplasty
Figure 28 shows the postoperative radiograph of a 36-year-old patient. The cerclage cable was placed for a minimal medial calcar fracture seen during femoral preparation. In the immediate postoperative period, what is the highest level of activity that would be safely permitted?
Immediate full weight bearing
Toe touch weight bearing
50% weight bearing
A 75-year-old woman undergoes hybrid total hip arthroplasty for osteoarthritis. A postoperative radiograph obtained in the recovery room is shown in Figure 18. Treatment should now consist of
open reduction and internal fixation with strut graft and cerclage wire.
open reduction and internal fixation with a plate, screws, and bone graft.
exchange of the femoral components with insertion of a long stem cementless implant.
minimal weight bearing and observation.
Figure 16 shows the radiograph of an otherwise healthy 62-year-old woman who fell. Management should consist of
revision total hip arthroplasty with a cemented femoral component and adjuvant fracture fixation.
revision total hip arthroplasty with a cementless femoral component and adjuvant fracture fixation.
open reduction and internal fixation of the fracture and retention of the original components.
removal of the components, open reduction and internal fixation of the fracture, and delayed replantation of the components when the fracture is healed.
resection arthroplasty and internal fixation of the fracture.
Figure 10 shows the AP radiograph of an ambulatory 76-year-old patient. What is the most appropriate surgical treatment option for this patient?
Revision arthroplasty using a cemented femoral component
Impaction allografting of the femoral component
Proximal femoral replacement arthroplasty
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?
Revision total hip replacement with a proximally coated femoral stem
Open reduction, internal fixation with plate and cerclage wires
Proximal femoral replacement with megaprosthesis
Impaction bone grafting
Cortical strut allograft with cerclage wiring
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?
Traction for 6 weeks followed by slow return to weight bearing
Revision to a long, cementless femoral stem
Revision to a long, cementless stem with strut allograft
Revision to a long, cemented stem
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?
Continued insertion of the stem, cerclage wiring around the fracture site, and non-weight bearing x6 weeks
Continued insertion of the stem, reduction of the hip, and non-weight bearing activity restrictions following surgery
Removal of the stem, cerclage wiring around the fracture site, and re-insertion of a stem
Removal of the stem and conversion to a cemented femoral stem
Removal of the stem, open reduction internal fixation of the femur with planned delayed femoral stem insertion following fracture healing
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?
Open reduction internal fixation with a cable plate
Revision of the femur with a long, cementless stem
Revision of the femur with a long, cemented stem
Girdlestone resection arthroplasty
While performing a cementless total hip arthroplasty in a healthy 68-year-old female, the surgeon notes an audible change while impacting the final broach. The broach is removed and a 1cm longitudinal crack originating at the calcar is visualized. Bone stock is otherwise preserved. What is the next best step in management?
Insert standard press-fit stem, weight bearing as tolerated postoperatively
Apply cerclage wire, insert standard press-fit stem, weight bearing as tolerated postoperatively
Insert long porous-coated stem, touch down weight bearing postoperatively
Insert long cemented stem, weight bearing as tolerated postoperatively
Insert long porous-coated stem, augment with cortical allograft and cerclage wires, touch down weight bearing postoperatively.
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?
Revision of the acetabular component and ORIF of the femur with locking plates and cerclage wires
Revison of the femoral component, bypassing the fracture by two cortical diameters
Revision of the femoral component with impaction grafting and cerclage wires
Revision to a cemented component, bypassing the fracture by two cortical diameters
ORIF of the femur with locking plates and cerclage wires