Journal Club Periprosthetic # 1

7/29/2019 Journal Club Periprosthetic # 1

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Periprosthetic fractures relatively commonand are challenging!

Incidence: Primary THR (Cemented Stems)


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Elderly patients

Poor bone quality Co-morbidities

Lengthy procedures

Increased length of stay Prolonged rehabilitation

Surgical expertise Expensive!


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By Duncan and Masri in 1995

High Inter and Intra observer reliability Proposes an accurate and effective treatment

protocol


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Can occur intr-operatively

Associated with osteopenia /osteolysis

Mostly non-operative

management; unless extend intocalcar / affect stability

Managed by cables / Trochantericplates


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Fracture distal to intertrochanetric

region, but around the stem By definition- A well fixed stem!

Morphology of fracture dictatestreatment options

Cable / Circlage wiring +/ plating (uni/

biplanar) +/ cortical strut onlay allograft(for local osteolysis)


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Fractures around stem leading to looseningand involving cement mantle

Loosening of stem determined on x-rays / intr-

operatively Subsidence, shift in stem position, lucency in

bone cement interface (Gruen zones),osteolysis and reactive sclerosis around stem.

Best treated by Uncemented modular longRevision stems-bypassing the fracture site by2 femoral cortical diameters (at least 7cm).

Role of cemented stem revisions-very minimal


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Fractures associated with osteopenia or

deficient bone Treatment dependent on patients age and

activity level Allograft prosthetic composite reconstruction Proximal femoral replacement


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Fractures distal to stem Tip

Treated by ORIF- Plating +/ cables / wires Retrograde nailing for very distal fractures ?


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Differentiation of B1 /B2 is most challengingand detrimental in management andoutcome

1 year mortality rate for Type B fractures:Treated by Revision arthroplasty 12%Treated by ORIF 33%

Increase in 1 year mortality rate if surgerydelayed for > 2 days from admission!


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Retrospective study

146 patients treated between 1999-2009 62% Female, Mean age 79 years

Fractures around THR-63, Revision-27, Hemi-57

Non operative- 23 cases ORIF-61 Cases

Revision-62 cases


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Cost of ward per day- 460

Elderly ward ICU and HDU

Cost of theatre time / per hour 480 All investigations cost Not included-Long term residential /

institutional care


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Avg length of stay

38 days Total cost of treatment for

all patients-3,426,483

Avg cost per pt-23,469

,(20,172)


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No statistical difference between treatment modality

No statistical difference between THR / Hemi #

No statistical difference between 2 medical co-

morbiditiesSignificant difference in cost between one procedureand > 1 procedure (p=0.01)

Length of stay >30 days had significant impact on

costing (p


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Avg Hospital cost 23,469

Main components of cost Length of stay 80%

Op-time 6% Implants cost 7% Investigations 7%

Complications of treatment has high impacton further costs


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Study highlights the financial implications of

these increasingly common fractures

Large series from tertiary centre If 30 days staydespite no major complications in some cases

Implant costings only 7%? Accuracy of cost analysis is questionable?

Journal Club Periprosthetic # 1

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