3. Definition
⢠Periprosthetic refers to structure in close relationship to an implant.
⢠Periprosthetic Fracture refers to fracture in close relationship to an
prosthesis
⢠Pose unique fixation challenges
⢠Needs MDT, Orthogeriatrician, Revision Surgeons, Trauma Surgeon,âŚ.
⢠Need planning
4. Orthopedic Importance
⢠The third most common indication for revision surgery
⢠Important to establish the principles of management which are most
likely to provide the greatest chance of a satisfactory outcome.
⢠Need for a brief comprehensive classification system on which to base
algorithms of treatment.
5. Incidence
⢠0.5% to 3.9% (1° replacement & cemented)
⢠3 x increase in uncemented Replacement and a further 3 x increase in
uncemented Revision
⢠May rise even further:- increased life expectancy, elderly population
and Osteoporotic bones.
⢠Cemented THR and OA correlate with low prevalence.
⢠Higher mortality rates after revision surgery for PF compared with
revision for other causes
6. Incidence
⢠Primary Arthroplasty
⢠Cemented 0.3% - 3.5%
⢠Uncemented (3 x 1° cemented)
⢠Revision Arthroplasty
⢠Cemented 3.6%
⢠Uncemented (3 x Rev Cemented)
⢠The average time for 1° Arthroplasty to fracture is 7.4 years and the
number decreased with revision Arthroplasties to 3.9 years.
⢠Tibial PF are less common 0.4% in the 1° arthroplasty and higher in Rev
arthroplasty
⢠Number of periprosthetic fractures is expected to rise by a mean 4.6%
every decade over the next 30 years.
7. Impact on mortality
⢠11% at 1 year â periprosthetic fracture
⢠16.5% at 1 year - # NOF
⢠A nearly 3 x increase in mortality in patients who sustained a fracture
at the level of the prosthesis.
⢠Economic impact
8. Risk Factors
Poor bone quality
⢠Major Risk factors:- female, Revision surgery, Age,
higher BMI
⢠Osteopaenia, Osteolysis, Osteoporosis
⢠Medication related such as Chronic steroid
⢠Diabetes
⢠Pagets disease , DDH
⢠Stress shielding
⢠Stiffness
⢠Neurological condition:- Epilepsy, Parkinsonâs,
Ataxia, Myasthenia.
⢠Inflammatory arthritis RA, OA
⢠Infection
Surgery related
⢠Cemented Arthroplasty correlate with low
prevalence
⢠Notching phenomenon
⢠Malposition of a component
⢠Over resection
⢠Aggressive broaching
⢠Stable/unstable cementless stem
⢠Stability of cemented components
⢠Fracture characteristics
⢠Pedestal sign
⢠Cement mantle fracture
⢠Lucency at cement-bone/cement mantle
⢠Proximal bony overgrowth
9. Surgeon related
⢠Choice of implant
⢠Inadequate exposure
⢠Under reaming
⢠Overzealous reaming
⢠Aggressive broaching
⢠Heavy impaction
⢠Mal-positioning
⢠Patient/Prosthesis
10. Aetiology / Mechanism of Injury
⢠Loose stem with osteolysis
⢠Minor trauma or fall 85 â 90%
⢠High energy injury 8%
⢠No trauma / insidious
⢠Notching of the bone
⢠Osteoporosis
⢠Excessive wear
11. Common site of periprosthetic fractures
⢠Hip
⢠Knee
⢠Ankle
⢠Shoulder
⢠Elbow
12. Presentation
⢠Emergency
⢠Resuscitation
⢠ATLS
⢠Elective
⢠Clinical history
⢠Biodata
⢠Mechanism of Injury; fall, osteolysis or combination
⢠Pre-trauma history
⢠Pain before injury
⢠Details of implant; manufacturer, model, size,
⢠History of infection/ malignancy
⢠FSHx, Drug Hx
⢠Co-morbidity
15. Classification
⢠Every Single anatomic joint have been evaluated by dozens of
classifications
⢠Each may represent a slight adjustment of the previous
⢠The previous may become redundant
⢠Unified Classification system for Periprosthetic fractures (UCPF)
⢠Alphabetical in it core design
⢠UCPF core principle
⢠The location of the fracture
⢠The fixation of the component
⢠The adequacy of the bone stock and bone strength supporting the implant
17. Classification Contâd
⢠Acetabular PF
⢠Peterson and Lewallan Classification
⢠Type 1:
⢠Radiologically stable component
⢠Gentle passive ROM of the hip cause little or no pain
⢠Type 2:
⢠Radiologically unstable component (displaced # or loose sheâll)
⢠Pain with any motion of the hip
⢠NB: no consideration for fracture location and morphology
18. Classification Contâd
⢠Modified Letournel classification
⢠Describes the location of the
fracture
⢠Medial wall
⢠Posterior column
⢠Transverse fracture and
⢠Anterior column fracture
19. Classification Contâd
⢠Femoral PF with THR
⢠Vancouver classification based on:
⢠Location of fracture relative to the
stem
⢠Stability of implant and
⢠Bone stock
⢠Either
⢠Intra â operative
⢠Post â operative
20. Classification Contâd
⢠Femoral PF with TKR
⢠Lewis and Rorabeck
⢠Type I: Undisplaced fracture with intact
prosthesis
⢠Type II: Displaced fracture with intact
prosthesis
⢠Type III: Displaced or undisplaced
fracture with loose prosthesis or failing
prosthesis
⢠Su et al classification: type 1,2,3
21. Classification Contâd
⢠Tibia PF with TKR
⢠Felix classification
⢠Subtype:
⢠A: Prosthesis well â fixed
⢠B: Prosthesis loose
⢠C: Intra â operative
⢠TypeI: Tibial Plateau
⢠TypeII: Adjacent to stem
⢠Type III: Distal to prosthesis
⢠TypeIV: Tibial tubercle
22. Classification Contâd
⢠Periprosthetic Patella Fractures
⢠Ortiguera and Berry classification
⢠Type I: Stable implant intact extensor
mechanism
⢠Type II: Disrupted extensor
mechanism, stable or loose implant
⢠Type III: Loose implant, intact
extensor mechanism
⢠Goldberg Classification
23. The Principal of Treatment
(UCS of PF A,B,C,D,E and F)
⢠Type A:
⢠Two questions need to be answered
⢠(1) How important is the attached soft
tissue to the health and function of the
adjecent joint replacement?
⢠(2) Is the fracture displaced?
⢠If unimportant, the fracture may be safely
observed, even if displaced
⢠Coracoid process
⢠Lesser trochater
⢠If important, especially if displaced early
intervention should be considered
⢠Supraspinatus to greater tuberosity of the
humerus
⢠Quadriceps to the superior pole of the patella
⢠Greater trochater
⢠Tibial tuberosity
24. Principle of treatment Contâd
⢠Type B:
⢠Management is determined by the subtype.
⢠If it is B1 where sound fixation of the implant is assured, management will
depend on;
⢠The already documented outcomes of operative or non-operative treatment of that
particular type of fracture eg MIPO in well fixed proximally coated Stam in a femur
⢠If B2, and the surrounding quality of bone will permit it, revision with a longer
stem is a common approach
⢠In the case of B3, a more complex reconstruction should be considered with
extensive pre-operative planning
26. B3
⢠Severe osteolysis and loosening
of the stem
⢠Treated with:
⢠Plate fixation
⢠Long stem revision component
⢠Allograft strut
⢠Cerclage wiring
27. Principle of treatment Contâd
⢠Type C:
⢠If sufficiently distant from the bed of the implant, the implant can be
ignored
⢠Fundamental principle of management would follow those employed
as if the implant was not present
⢠Specialized techniques may have to be used
⢠If hardware required will extend to the bed of implant
⢠Such as cerclage cables
⢠Such as unicortical screws
29. Principle of treatment Contâd
⢠Type D:
⢠The term 'block out analysisâ has been coined for type D
⢠For instance, femoral PF between a hip and knee replacement, block
out the knee and ask 'what type of # is this for the hipâ?
⢠Next block out the hip and ask the same question with reference to
the knee
⢠A rational approach can then be planned based on this analysis
⢠May involve revision of one, both, or neither joint replacement
⢠A type C(for each) between well functioning & well fixed hip and knee
would employ MIPO without the need to disturb either replacement
31. Principle of treatment Contâd
⢠Type E:
⢠Block out analysis of each
fracture should be under taken
in relation to each component of
the joint replacement
⢠A logical treatment plan can be
developed
32. Principle of treatment Contâd
⢠Type F:
⢠In fracture with minimal
displacement
⢠It would be appropriate to take a non-
operative approach
⢠With protected weight bearing
⢠Using the implant as a mould
⢠A delayed and relatively straight
forward conversion to either THR,
TKR, TAR, TSR or TER could be
considered later if there are
persistent symptoms
⢠If the initial displacement is
substancial, early intervention is
considered except if:
⢠In dementia
⢠Not able to cooperate
⢠If patient is not ambulant
⢠Fragile state of general health
⢠Same principle applied to a native ;
⢠Glenoid after hemi-arthroplasty of
the shoulder
⢠Unresurfaced patella
⢠Lateral humeral condyle articulating
with radial head implant
33. UCSof PF type F
(mildly displaced & substancial displacement)
34. UCS of PF type F
⢠Kerboull acetabular device &
cemented dual mobility cup
35. UCS of PF type F
⢠One stage surgery
⢠ORIF of the anterior column
through Stoppa approach
⢠Revision of cup through direct
anterior approach
⢠Reconstruction of the
acetabulum & cemented dual
mobility cup
36. UCS of PF type F
⢠A Type #
⢠ORIF of the anterior column
using Stoppa approach
⢠Orif of the posterior column &
acetabular reconstruction using
a Burch â Schneider
Antiprotrussio cage via a Kocher
â Lagenbeck approach
37. Intra-operative Principles
⢠The complexity of PF often leads
to suboptimal management and
poor results
⢠Non-operative management has
poor means of treatment,
surgery without question is the
standard mode of treatment
⢠Intra-operative Vancouver
classification
⢠A: proximal metaphysis
⢠B: Diaphysis
⢠C: Distal to stem tip
⢠1. Perforation of cortical bone
⢠2. Non displaced crack
⢠3. Displaced / unstable crack
38. Intra-operative Principles Contâd
⢠Risk factors to intra-operative #
⢠Under ream >2mm
⢠Impaired bone quality
⢠Cementless component
⢠Dysplastic bone
⢠The type of implant size and shape
eg elliptical modular cup
⢠Signs of intra-operative #
⢠Sound of crack
⢠Sudden change in resistance
⢠Abnormal movement
39. Intra-operative Principles Contâd
⢠Stable Intra-operative
⢠Observation
⢠Bracing
⢠Use of cast
⢠Protected weight bearing
⢠Unstable intra-operative
⢠Revision with screws/ exchange of cup / exchange of implant
⢠Open reduction and internal fixation
⢠Bone graft application
⢠Protected weight bearing
40. Intra-operative Principles Contâd
⢠Treatment options
⢠Stem removal, Cable application and
reinsertion
⢠Apophyseal fixation with cables or
claw plate
⢠Removal of implant with insertion of
longer stem
⢠Remove implant, do ORIF and
reinsert implant
⢠Replacement
⢠Cemented
⢠Uncemented extensively coated
⢠Uncemented fluted tapered
⢠Uncemented + Locking screws
⢠Tumour implants
⢠Implant sources
⢠DePuy
⢠Zimmer
⢠Stryker
⢠Biomet
⢠Smith â Nephew
⢠NOHI
41. Intra-operative Principles Contâd
⢠Technique
⢠Selection of anaesthesia
⢠Positioning
⢠Srick asepsis
⢠Prophylactic antibiotics
⢠Gentle soft tissue handling
⢠Maintain vascularity with minimal muscle
stripping
⢠Save fragments
⢠Bypass fragments with appropriate implant
⢠Allow bone to reconstitute with healing
response
⢠Access implant through fracture lines or
osteotomy
⢠Use prosthesis as internal scaffold; pull
sleeve of bone & soft tissue around it
⢠A of the treatment
⢠Aim is to get a functional, stable limb so
that patient is able to perform ADL
42. Intra-operative Principles Contâd
⢠Revision Principle
⢠Use the fracture for access to remove implant
⢠Bypass the fracture with long stem
⢠Stabilize fracture
⢠Get stable implant fixation
44. Prognosis
⢠Mortality following a PF (89% 1 year survival) is :
⢠Significantly greater than the mortality after primary joint replacement (97%
1 year survival) in matched patients
⢠And statistically similar to the mortality following NOF fractures (83.5%)
45. West African Perculiarities
⢠Relatively new and evolving subspecialty in our region
⢠Constraints include:
⢠Poverty
⢠Lack of reliable health insurance
⢠Ignorance & illiteracy leads to late presentation with complex pathology
⢠Increased risk of revision
⢠Limited expertise as MDT
⢠Poorly developed infrastructure leading to peri-operative challenges
⢠TBS acceptance
46. Conclusion
⢠Principle of management of PF is still an evolving technique
⢠Fracture pattern, Patient factors, and healing potential must be
considered
⢠Emphasis on simultaneously creating strong, durable mechanical
construct
⢠Optimization of the biologic environment for fracture healing
47. Referreces
⢠The Swedish Hip Registry 2011. http://www.shpr.se/Libraries/Document
⢠Duncan CP, Haddad FS. Classification.,In: Shutz M, Perca C,Ruedi TP,Ed
Periprosthetic Fracture Management Vol 1. New York: 10001
⢠Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr
course lect 1995; 44: 293- 304
⢠The Unified Classification System (UCS): improving our understanding of
periprosthetic fractures
⢠XXV Congress SLAHOC 2021, Quito- Ecuador, Actualization en cirugia de
codo, Antonio M Foruria Fractures perprotesicas de codo
⢠Orthopaedic Grand Rounds, on periprosthetic fractures at University of
Washington medical center on uwtv
