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Management of Periprosthetic Fractures After Arthroplasty
- 1. Management Periprosthetic fracture after Arthroplasty • Chun-Hao Tsai, MD • 中國醫藥大學 附設醫院 • 骨科部 副教授 蔡俊灝 醫師 2020-09-19 台灣骨科創傷醫學會專家學術論壇
- 2. Periprosthetic Fractures • New challenge • More population • Increase Patient age and prosthesis Longevity • New design of prosthesis • Variety of joint anatomy/mechanical articulation
- 3. Before you go, check it… • Clinical suspicion • Source of pain • Compatible anatomic finding with symptom • Pain or instability +/- trauma history • Occult trauma ? • Source of fracture • Osteolysis of bearing wear • Osteolysis due to infection • Malposition of the prothesis/ implants
- 4. Prosthesis • Loose /Osteolysis /Malalignment Evaluation of stability of prosthesis by history and image Plain X-ray +/- CT evaluation INFECTION • Explanation • Debridement • Temporary Fixation /External Fixator • Antibiotic Cement Spacer • Definitive Arthroplasty Test for infection Laboratory test/Bone scan/aspiration biopsy NO INFECTION • CT /MRI/DEXA • Revision arthroplasty
- 5. The fracture is usually worse than it looks (pre op planning is essential)
- 6. Unified Classification System (UCS) Duncan, Haddad • The UCS is alphabetical in its core design for ease of application • Core principles A. The location of the fracture B. The fixation of the component C. The adequacy of the bone stock and bone strength supporting the implant
- 7. Unified” or “comprehensive” classification system for all periprosthetic fractures Joints I. Shoulder II. Elbow III. Wrist IV. Hip V. Knee VI. Ankle Bones AO/OTA Classification Types A-F “Vancouver " {P., 2014 #37} • A: Apophyseal • B: Bed of Implant • C: Clear of implant • D: Dividing the bone between two implant • E: Each of two bone supporting one arthroplasty • F: Facing and articulating with hemiarthoplasty
- 10. The Goal Of Treatment Good alignment Provide stability Early mobility Few complications as possible
- 11. Outline • Unified Classification System for Periprosthetic Fractures (UCS/CCS) • Periprosthetic THA Fractures IV • Periprosthetic Proximal Femur Fractures IV.3 • Interprosthetic femoral fractures IV.3D • Periprosthetic acetabular fractures IV.6 • Periprosthetic TKA Fractures V • Distal femoral Periprosthetic Fractures in TKA V.3 • Tibial Periprosthetic Fractures in TKA V.4 • Patellar Periprosthetic Fractures V.34 • Medial plateau Stress fracture after UKA V.4
- 12. • Periprosthetic THA Fractures IV • Periprosthetic Proximal Femur Fractures IV.3 • Interprosthetic femoral fractures IV.3D • Periprosthetic acetabular fractures IV.6
- 13. Periprosthetic Proximal Femur Fractures Comprehensive Classification System (CCS) IV.3
- 14. Hip arthroplasty periprosthetic femoral fractures • Incidence of periprosthetic hip fracture • 0.4-4.6% of all total hip replacements • Big Surgery • Aquamantis- especially for obese patients • Cell saver unless infected • Midas rex for osteotomy • Type and cross 4-6 units • General anesthesia
- 15. Decision questions •Vancouver A • Watch or ORIF trochanter • Vancouver B •Stem stable 1 = ORIF •Stem loose 2 = Revision Stem •Stem Loose + No diaphysis = ORIF + Rev Stem
- 18. Options • Longer GTR • Dall-Miles cable plate • Reverse distal femoral locking plate • polyaxial locking plate
- 19. Vancouver B1 Stem stable = ORIF • Plate • ENTIRE femur? • Modular implant • Cables / Struts? • Optimal? • Augmentation?
- 20. Vancouver B2 Stem loose = Revision Stem • Springer et al , JBJS(A) 2003 • Extensively coated stem >Long cemented stem > Long proximally coated monoblock stems • Munro J. T. BJJ 2013 • Tapered fluted modular titanium stem
- 21. Vancouver B3 Stem Loose + No diaphysis = ORIF + Rev Stem • Tapered fluted modular titanium stem • Bypass fracture • Gains both axial and rotational stability distal to the fracture site • Save proximal fragments • Allow proximal femur to reconstitute with healing response {Richards, 2008 #2}
- 22. “INTERNAL SCAFFOLDTECHNIQUE” • Transfemoral approach • Access only through fracture lines, osteotomy • Use prosthesis as internal scaffold, pull sleeve of bone and soft tissue around it • Place prophylactic cable at mouth of distal fragment {Abdel, 2014 #7;Berry, 2003 #6;Richards, 2008 #2;T., 2013 #4}
- 23. 1381 FRACTURES TREATED IN SWEDEN BETWEEN 2001 AND 2011 • Higher risk for reoperation • Interprosthetic • Type B1 fractures • For B1 fractures • conventional (26%) vs locking plate osteosynthesis (19%). • No significant difference • Type B2 and B3 fractures • Cemented • Cementless monoblock • Cementless modular revision components • No significant differences {Chatziagorou, 2019 #22}
- 24. Stem fracture alone or accompanied by PPFF FS {Huang, 2018 #36} proximal portion of the fractured stem stable proximal portion of the fractured stem is loose and the surrounding bone quality is good proximal portion of the fractured stem is loose and the bone is poor quality
- 25. Implant fracture • Alone : revision • Bone fracture : revision + fixation/reconstruction
- 26. Comprehensive Classification System (CCS) IV.6 Periprosthetic acetabular fractures
- 27. Classification • 2014 Ducan and Haddad classification • IV,6 Acetabulum/pelvis • B1: Prosthesis stable, good bone: Acetabular rim or floor, good bone • B2: Prosthesis loose, good bone: Loose cup, good bone • B3: Prosthesis loose, poor bone or bone defect: Loose cup,poor bone, defect; Pelvic discontinuity
- 28. Pascarella 2018 Timing Prosthesis stability Treatment 1. Intraoperative fracture a. Prosthesis stable Conservative treatment s / increase primary stability with screws b. Prosthesis unstable ORIF if displacement > 2 cm / acetabular ring with screws/ Implant revision 2.Postoperative /Traumatic fractures a. Prosthesis stable Conservative treatment/ ORIF b. Prosthesis unstable, mobilized simultaneously trauma Implant revision/ acetabular ring /ORIF c. Prosthesis unstable, mobilized before trauma (osteolysis/bone loss) Implant revision/ acetabular ring /ORIF /bone graft
- 29. {Pascarella, 2018 #50} 1A ORIF without cup revision 2AConservative treatment
- 30. 2c • Acetabular component was mobilized before trauma • Acetabular ring, cemented cup {Pascarella, 2018 #50} {Resch, 2016 #51}
- 32. Interprosthetic femoral fractures V.3D {Pires, 2017 #49;Pires, 2014 #39}
- 33. {Pires, 2017 #49;Pires, 2014 #39}
- 38. Periprosthetic fracture beween DHS and TKA 83 years old female
- 39. Unified Classification System for Periprosthetic Fractures (UCPF) V.3D Dividing the bone between two implants or interprosthetic or intercalary
- 40. ORIF with NCB and DCP, osteoset 83 years old female , falling down
- 43. Distal femoral Periprosthetic Fractures in TKA •0.3-2.5% of TKA •Most common periprosthetic fracture •Mortality of geriatric DFF • 6% 30 days • 18% 6 months • 25% 1 year •Comparable to geriatric femoral neck fracture • {Konda, 2015 #31}
- 44. Distal femoral Periprosthetic Fractures in TKA • Risk factors for Periprosthetic Distal femoral Fracture around TKA • Stiff knee • Anterior femoral notching • Neurological abnormalities • Revision knee arthroplasty
- 45. Challenges to fixation • Fracture location/pattern • Implant characteristics • Other implants THA, CMN (long/short), DHS • Residual bone stock in distal segment • Bone quality • Stress shielding • Osteolysis
- 46. Classification
- 47. Periprosthetic DFF Stable implant Unstable Implant Good bone stock Poor bone stock DFR ORIF + revision TKA Poor bone stock Metaphyseal ORIF Diaphyseal IMN Healthy Patient DFR Unhealthy Patient ORIF +/- augmentation
- 49. • Antegrade intramedullary nail • Su Type I • Retrograde intramedullary nail • Su Type II • Revision to a long stem prosthesis • Lewis-Rorabeck III or Su Type III (described above) with poor bone stock • Distal femoral replacement
- 50. ORIF with fixed angle device • Indications • Intact/stable prosthesis • Lewis-Rorabeck II or Su types I or II or III) internal fixation • Condylar buttress plate (non-locking) : not resist varus collapse • Locking plates • Blade plate / dynamic condylar screw • Difficult to get adequate fixation around PS implants • Intramedullary nail • Nail/plate constructs
- 51. Locking Plates • Advantages: • Multiple screw options • Fixed angle – prevents varus collapse • Fixation in the setting of comminution • Mechanical advantage in poor distal bone stock • Span entire femur, avoid stress riser • Do NOT fill every hole • Locking vs nonlocking diaphyseal screws
- 52. Intramedullary Nailing • Load sharing • Immediate weight bearing • Biologically friendly • Stimulates secondary bone healing • Fixation • Prevent malalignment • Full extension • Blocking screws
- 53. Intramedullary Nailing: Ante- or Retro-graded • Distal fixation • High screw density distally • At least 3-4 screws • Multiplanar fixation • Proximal fixation • Isthmus provides additional fixation • No short nails – windshield wiper {Fakler, 2017 #30}
- 54. Double LCP
- 55. Nail Plate Combination Technique J Orthop Trauma Volume 33, Number 2, February 2019
- 56. • rIMN first • Lateral plate :proximal end at the base of the greater trochanter • Accommodate the femoral neck anteversion (arrow) for screw placement • Proximally, a nonlocking drill bit is provisionally placed to hold the center position of the plate
- 57. Distal Femoral Replacement (DFR) in fractures ORIF is likely to fail or already has.
- 58. Revision with extended stem LCCK TKA and cones
- 59. Retrograde IMN: LCP 11 min shorter KSS one point higher similar clinicoradiologic outcomes Time to unionOperation time Post-operative knee society scores Nonunion {Shin, 2017 #19}
- 60. Revision Options • ORIF with smaller revision • for well fixed implants or fractures with implant wear, failure or loosening but good distal bone stock • Poly exchange • needed if IMN takes out the PCL (adds flexion laxity and loses posterior stability). • if there is symmetric extension and flexion gap • ORIF with stemmed revision implants
- 61. • Allograft-Implant Composites • RHK • rate of prosthetic survival • 79.6% at one year • 68.2% at five years with revision or reoperation • salvage procedure not used as routine • removing more bone and is more conducive to future revision • Distal Femoral Replacement Prosthesis • lderly, lower demand, compromised distal bone stock, loose implant. • Poor Bone Stock, Fractures comminuted and extend quite distal • Frequently occur in the setting of remote TKA with poly wear and osteolysis {Saidi, 2014 #35} {Mortazavi, 2010 #33}
- 63. Tibial Periprosthetic Fractures in TKA • Incidence : 0.4%-1.7% • Fracture specific risk factors • Prior tibial tubercle osteotomy • Revision knee arthroplasty • Component loosening • Component malposition • Insertion of long-stemmed tibial components
- 64. Felix and Associates' Classification of Periprosthetic Fractures of the Tibia Associated with TKA • Classification • Type I Fracture of tibial plateau • Type IIFracture adjacent to tibial stem • Type III Fracture of tibial shaft, distal to component • Type IV Fracture of tibial tubercle
- 65. Operative • Indications • Unstable fracture with stable prosthesis ORIF • Indications • Displaced fractures with loose tibial component Long- stem revision prosthesis
- 66. • AO classification V.4C / • Felix classificaton Type III
- 67. AO classification V.4C / Felix classificaton Type III
- 70. Complication-MIPO • Malalignment • Soft tissue infection Author Year n Central message Schreiner et al 2018 9 Soft Tissue Management, Correct Alignment Kim et al 2016 16 Malalignment Seeger et al 2013 12 Higher Fracture Tabutin et al 2007 6 IMN Thompson et al 2001 7 Malalignment {Kamal, 2020 #28}
- 71. Comprehensive Classification System (CCS) V.34 Patellar Periprosthetic Fractures
- 72. Incidence • 0.2%-21% in resurfaced patella • 0.05% in unresurfaced patella Fracture specific risk factors • Patellar osteonecrosis • Asymmetric resection of patella • Inappropriate thickness of patella • Implant related • Central single peg implant • Uncemented fixation • Metal backing on patella • Inset patellar component
- 73. Operative • Indications • Loose patellar component • Extensor mechanism disruption • Techniques • ORIF with or without component revision • Partial patellectomy with tendon repair • Patellar resection arthroplasty and fixation • Total patellectomy {Anderson, 2009 #5}
- 74. Medial plateau Stress fracture after UKA V.4-B 0.2% {Liddle, 2014 #65}
- 75. 78 year-old F, left knee pain
- 77. /p 2 week start tibia plateau subsidence
- 78. /p 4 week progressive tibia plateau subsidence
- 79. /p 6 week progressive tibia plateau loosening
- 80. Revision with TKA with stem and plate
- 81. Risk factor for periprosthetic stress fracture after UKA Patient factor Tibia varus /Body weight Osteoporosis Avoid BMI>30 ,82 kg Implant factor Tibia EM guide with pin hole Avoid excessive pin hole cementless UKA Re-cut spacer Avoid additional pin hole if recut needed Tibial tray with keel and peg Precaution if hit into sclerotic bone Surgeon factor Sagittal cut Avoid over cut and damage posterior cortex Implant insertion Avoid forceful Sizing Avoid under size Position Avoid over medial with overhang Alignment Avoid excessive varus Rehabilitation Weight-bearing status Consider protected weight-bearing if doubtful
- 82. Over-Cut • Weakening of the condyle • Posterior tibia cortex (most) resection • Too deep • Too medial • Anterior cortex • One pin technique • Remove too much bone to weaken the reminder
- 83. Tibial component alignment angle (TCAA) Stress fractures • Shoulder natural to MPTA • Larger post-op TFA + TCAA (over-varus cut) • Low BMD at the PF in the affected leg{Yokoyama, 2019 #62}
- 84. Excessive varus • The recommended position • (Solid tibial tray outline) • Perpendicular to the mechanical axis of the tibia. • The varus component • (dotted tibial tray outline) • A larger size and the keel • Further from the medial cortex. {Hiranaka, 2020 #55} • Japanese patients • Tibia vara • Medial eminence line (MEL) • Tibial axis (TA) IM EM
- 85. Treatment • /p <3 Ms • Non-displaced • avoid weight-bearing for 6 weeks • High failure rate • Displaced • Support plate fixation {Lu, 2019 #57;Hiranaka, 2020 #55} • /p >3 Ms • United and accept varus: OBS • United , but pain • → Tc loosening →rev-TKA • Not union • Knee revision • Stem+ Augmentation
- 86. I shoulder
- 87. I.14-A1 coracoid process SCAPULA I.14-A2 acromion
- 88. Scapular Glenoid I.14-B1 I.14-B2 I.14-B3
- 90. Proximal Humerus I.1-A1 GT I.1-A1 LT I.1-B1 I.1-B2 I.1-B3 I.1-C I.1-D
- 91. II Elbow
- 92. II.1-A1 Lateral Condyle II.1-A1 Medial Condyle II.1-A1 Tip of olecranon II.2-A2 coronoid process
- 94. II.1-D II.1-F
- 95. Allograft struts and impaction grafting ,cerclage/plate fixation
- 97. III WRIST
- 99. VI Ankle
- 102. Take Home Message
- 103. Conclusion • Establish accurate diagnosis • Identified the mode of failure , aware of infection • recognize the mechanical alignment -stability of the prosthesis • Preserve bone stock • Vancouver classification still reliable • Consider the bone quality of the patient /bone stock for / differ in upper-lower limb • Allograft Structural bone graft augmentation/impact bone graft • Restore the articulation • Reduce risk of complication