periprosthetic fracture

1. Periprosthetic Fracture
Dr. Jatinder S. Luthra
(MS , DNB, MRCS)

2. Projected Primary and Revision TKR
673% Increase in Primary TKA
Kurtz et al JBJS 2007
601% Increase in Revision

3. Oman perspective

4. Incidence
• Mayo Clinic – Largest series ( 19810 primary tkr)
• Femur – 2%
• Patella – 0.5% - 1.0 %
• Tibia - 0.4%
• Average - 0.3% – 3.0 % Incidence
1.2%
Incidence
Revision surgery – 38%

5. Incidence
• With in 15 cm from joint line
• Stemmed implant - < 5cm from the tip of stem
• Low energy falls – 90 %

6. Risk Factors
• Increasing age
• Female
• Osteoporosis
• Revision arthroplasty
• Rheumatoid Arthritis
• Ch. Steroid therapy
• Arthrofibrosis
• Neurological diseases

7. Risk Factors
• Ant. Femoral Notching
• Biomechanical & Finite element analysis –
3 mm notching Bending & Torsional strength by 1/3
• Many Clinical studies – do not prove
• ? Bone remodelling
Debatable
Notching 28%
2 periprosthetic fracture

8. Classification
Type Rorabeck
I Fracture undisplaced
Implant stable
II Fracture displaced ,
Implant stable
III Implant Loose
Frature Un/displaced

9. Classification
Type Su
I Fracture proximal to
prosthesis
II Fracture starts at
prosthesis & extend
proximally
III Fracture distal to flange
of prosthesis

10. Classification
Type Felix - Classification
I Fracture of tibial plateau involving implant bone interface
II Fractuer of meta / diaphyseal transition
III Fracture distal to tibial component
IV Fracture of tibial tuberosity
Subtype
A Stable implant
B Loose implant
C Intraoperative fracture

11. Classification
Type Goldberg Classification
I Fracture not involving implant bone interface or
ext mech.
II Fracture involving Implant bone interface or
extensor mech.
III A - Fracture inf pole of patella with patellar lig
rupture
B – Fracture inf pole patella without patellar lig
rupture
IV All Types of fracture Dislocations

13. Diagnosis
• History
• Examination
• X- rays
• Ct scan
-Mech. of Injury
-Pain before injury
-Soft Tissue envelope
-Extensor mech.
-Ap
-Lateral
-Oblique
-Sunrise
-Surgical planning
-Component stability

14. Management
• Stable joint without significant malalignment
• Uneventful and complete fracture healing in
6 months
• Range of motion & Knee function prior to
trauma

15. Management
Nonsurgical – Brace / cast
• Undisplaced fracture with stable implant
Stiffness
Malalignment
Nonunion
Pain
AmbulatoryStatus

16. Management
Surgical options – Conventional Plate & Screw
• Indication
• Technique
• Advantages
• Disadvantages
-Displaced
-Minimally Comminuted
-Good Bone Stock
-Lateral Approach
-Minimal periosteal stripping
-3 screws in distal fragment
3 screws in proximal fragment
Augment with bone graft /
cement
Anatomic
reconstruction
Rigid fixation
Early ROM
Osteopenic Bones
Do Not work
High incidence
Non union
Malunion
Mechanical failure

17. Management
Surgical options - Locking Plate
Mainstay of managing these fractures
Indication
Technique
Advantages
Disadvantages
Lateral approach
Anterior approach
Polyaxial locking screws
Internal fixator
Bicortical fixation
Pull out from osteoporotic bone
Fracture reduced independent of plate – mal-aligned
Osteoporotic bones
Biomechanically Superior
Better Distal Fixation
Far Cortical Fixation
Reduced Construct stiffness
Retain strength
Symmetric callus
Bottlang et JBJS 2010

18. Management
Surgical options - Supracondylar IM nail
• Indication
• Technique
• Advantages
• Disadvantages
-Displaced
-Markedly Comminuted
-Open Box implants
Med. Parapatellar app.
Open with awl
Minimal stripping
Fracture haematoma undisturbed
Load Sharing Device
Reaming stimulate healing
Closed Box implants
C/f – very distal fracture

20. Evidence
Surgical options - Locking Plate
• Better ROM VS IM nail
Johnson et al Knee 2011
• Lower Malunion rate
Ristevski JOT 2011
• Lower Nonunion rate
Althausen etal JOA 2003
• Extreme distal Fracture
Streubal et al JBJS 2010

21. Evidence
Surgical options - Locking Plate
• Inconsistent and asymmetric Callus Formation
Lujan et al JOT 2010
• Nonunion rates – 28 %
Henderson et al CORR 2011
Boulton et al 2011
Gross etal 2011

22. Evidence
Compare locking plate & Nail
Case
reports/Series
No Trials
Large et al
Locking plate
better – ROM
No non union
No Difference

23. Management
Surgical options – Revision Arthroplasty
• Hinged Knee prosthesis - Majority
• Distal Femoral Replacement
• Indication
Severely comminuted fracture
Poor Bone stock
Very distal fracture
Loose prosthesis
Bone grafting - Debatable

24. Management - Algorithm
Periprosthetic Femur fracture
Open Box Design Closed Box Design
Stable Implant Loose Implant Stable Implant Loose Implant
Type I - II Type III Type I - III Type I - II Type III Type I - III
ORIF/CRIF
Locked plate
/
Retrograde
nail
ORIF/CRIF
Locked plate
/
Revision
Revision
Arthroplasty
Revision
Arthroplasty
ORIF/CRIF
Locked Plate
ORIF/CRIF
Locked plate
/
Revision

25. Management - Algorithm
Periprosthetic Patellar Fracture
Type I
Type II Type III
Exten
Mech.
Exten Mech
Intact
Implant loose
Intact
Conservative
Component
Remove &
reimplant after
bone healing
Exten Mech
Rupture
Implant stable
ORIF
A
B
Loose Stable Loose Stable
Explant
& recon
Recon/
SOS ORIF
Explant Conserv

26. Management - Algorithm
Periprosthetic Tibial fracture
Type I Type II Type III
A B
B A A B
Conservative
Change
Component
ORIF/CRIF
Lock Plate
Change
Component
+ORIF

27. Outcome
• Infection 3%
• Implant failure 4%
• Malunion 9%
• Revision Surgery 14%

28. Intraoperative fractures
• Femur – Diaphyseal fracture -stemmed implant
• Discovered post op – post pone weight bearing 6-
8 weeks till healing
• Femur – metaphyseal fracture
• – undisplaced conservative
• Displaced – intramedullary stem with
transcondylar screw

29. Ipsilateral hip and knee
• Avoid stress riser
• Overlapping of femoral stem with tibial plate
• Supplementary cables / strut graft
Locking attachment plate

30. Interprosthesis Distance
< 10 cm – overlap the two prosthesis
> 10 cm - ignore

31. Nailed Cementoplasty
• Bobak et al
JOA – 2010
5 patients – Advanced osteoporosis
ASA grade 3

32. Nail plate fixation

33. Miot Hospital Chennai

34. Femur Type 3 – Revision Arthroplasty

35. Femur – Type 2 – Locking Plate

36. Femur Type 3 – Locking plate

37. Felix Type 3 – Locked Plate

38. Summary
• Anterior fem. Notching – Femoral stem extension
• Avoid eccentric box cut
• Use stem to augment – wedges / graft
• Bypass the stress risers with stems – 2 canal
diameters
• Revision surgery -prosthesis removal in gentle
stepwise manner
• Tibial component removal – oscillating saw
• Severe osteopenia / unsteady gait – use a
cane/walker