Modern Techniques in Management of Periprosthetic Femoral Fractures After Total Hip Arthroplasty

8/2/2019 Modern Techniques in Management of Periprosthetic Femoral Fractures After Total Hip Arthroplasty

1/53


2/53

Prof. Dr. Ashraf Abd-Elkader ElnahhalProfessor of orthopedic surgery Faculty of Medicine Cairo University

Dr. Omar SolimanAss.prof. of Orthopedic Surgery Faculty of Medicine Cairo University


3/53

Periprosthetic femoral fractures after THR

Introduction

Periprosthetic fracture of the femur after hip arthroplastysurgery was first described by Horwitz et al., in 1954.

(Lindahl, Injury; 2007)


4/53

Factors leading to increase incidence ofPFF.

Introduction

Contentious increase No. of patients withTHA.

More younger patients.

Increased average life expectancy.

Increase number of patients with revised and

rerevised hips.


5/53

Periprostheticfemoral fractures

Intraoperative

fracturesPostoperative

fractures

Introduction


6/53

Incidence and etiologyof intraoperativefractures:

Incidence and etiology

Regarding the incidence of intraoperativefracture of the femur in primary hiparthroplasty they are estimated to occur in

about 1% of cemented stems and 3

18% ofuncemented stems .

The incidence is higher in revision settings up

to (21%).(Tsiridis et al., Injury

2003)


7/53

Use of cementless femoral components.


(JamesW & John R. Campbells Operative Orthopaedics.


8/53

Revision surgery:

Older patients.

Disuse osteopenia.

Femoral bone stock is oftendeficient.

Creation of corticalwindows for cementremoval.

Longer and larger diameterprosthesis.

Impaction graftingtechnique.



9/53

Complex deformities of the proximal femur.



I id d


10/53

Intra-pelvic protrusion:

Incidence andetiology



11/53

Incidence and etiologyof postoperativefractures:

Incidence and etiolog

The incidence in postoperative periprostheticfemoral fractures, has been estimated to be


12/53

Low-energy trauma:

o The most common etiology for late periprosthetic

fractures.

o 84% of periprosthetic fractures resulting as a

consequence of a fall

o 8% after other kinds of injuries

o 8% as spontaneous fractures

(Beals and Tower 1996).


nc ence an


13/53

Areas of cortical stress risers.

nc ence anetiology


14/53

Loosening of femoral component.



15/53

Osteolysis.Incidence and etiology

(William et al., JBJS am.; 1995)

I id d i l


16/53

Heterotropic bone formation.



I id d ti l


17/53

Systemic risk factors;

Diseases that may lead to generalized osteopenia e.g.;

rheumatoid arthritis

severe osteoporosis

Osteomalacia Pagets disease

Osteopetrosis

Osteogenesis imperfecta Thalassemia

Some neuromuscular disorders such aspoliomyelitis or parkinsonism



18/53

Management

The principle underlying the surgicalmanagement of periprosthetic fractures is thatconsideration needs to be given to the

fracture location, the stability of thecomponentsand the quality of theunderlying bone stock.


19/53

Vancouver classification:classification

Most recent and comprehensive.

Address important factors needed in management

ofperiprosthetic femoral fractures:

1. Fracture location.

2. Stability of the implant.

3. Quality of the femoral bone stock.

Simple, excellent interobserver reliability & validity.

(Sanjeev et al., Current Ortho. 2006)

classification


20/53

Vancouverclassification

Postoperativefractures Intraoperativefractures

classification


21/53

Intra-operative fracture classification:

The femur is divided into three zones, eachrepresenting a major type of fracture.

Each type then is divided into 3 subtypes:-Subtype 1: Simple cortical perforation.

Subtype 2: Undisplaced linear crack.

Subtype 3: Displaced or unstable fracture.

(Masri et al., clinical Orthopedics 2004)

classification

classification


22/53

Type A:Fractures are proximal metaphyseal, not

extending into the diaphysis.classification

Subtype 1: Subtype 2: Subtype 3:

classification


23/53

Type B:Fractures are diaphyseal.

Subtype 1 Subtype 2 Subtype 3

classification

classification


24/53

Type C: The fracture is distal to the stem tip and not amenable

to insertion of the longest revision stem.Subtype 1 Subtype 2 Subtype 3

classification

c ss c o


25/53

Post-operative fracture classification:

Consists of three major types based uponthe location of the fracture.

Each type A or B, subdivided into subtypesdepending on the stability of the implantand remaining bone stock.

(Duncan & Masri. AAOS; 1995)

classification

classification


26/53

Type A fractures:

Fractures in the Trochanteric region.

Type AG:fractures of

greater trochanter

Type AL:fractures of the

lesser trochanter

classification

classification


27/53

Type B fractures:

Fractures just distal or around the femoral stem.classification

Type B1:Stem well fixed

Type B2:Stem loose, good bone stock

Type B3:Stem loose, poor bone stock

classification


28/53

Type C Fractures:

Fractures well below the stem tip.

classification


29/53

Diagnosis of intraoperative fractures:diagnosis

Sudden change in the stability of the shaft.

Change in the sound of impact of the prosthesis.

Any suspicion of fracture an immediate

intraoperative radiograph is done.

(Callaghan , Instr. Course Lect. 1998)

diagnosis


30/53

Diagnosis of postoperative fractures:

Clinical features.

Radiographic features.

CT. or MRI.

diagnosis

Treatment options


31/53

TREATMENT

Non-

operative Operative

Treatment options

Treatment options


32/53

Current options for operative

treatment

Treatment options


33/53

Cerclage wire fixationTreatment options

Using stainless steel wires or multifilament cables. considered for:

Fixation of long oblique or spiral fractures around a well-fixedprosthesis.

Trochanteric fractures. (Sanjeev ,Current Orthopaedics:2006)

Treatment options


34/53

Plating:Treatment options

Indicated in diaphysealfractures that occuraround well-fixed

implants and distaldiaphysealmetaphyseal fractures.(Vancouver type B1, C)

(Tadross et al., J. Arthroplasty 2000)

Treatment options


35/53

Treatment options

Treatment options


36/53

Plate options:

Conventional compression plates:

Treatment options

(Haidar et al., Injury; 2005)

Treatment options


37/53

Plate options:

Cable and plate system:

Treatment options

Dall-Miles cable and plate system(Mabrey, Rockwood & Green's Fractures in Adults; 2006)

Treatment options


38/53

Plate options:

Locked plates:

Act as internalexternal splints.

Useful in fixation ofosteoporotic bone,

The periosteal

vascular supply isleast disturbed.

Can be Inserted

indirectly(MIPO).

Treatment options

Plate options: Treatment options


39/53

Plate options:

The Minimally invasive plate osteosynthesis(MIPO)

technique:

Indications:

Vancouver type B1 & typeC

Advantages:

Preserve bl. Supply.

Fracture hematoma.

plastic fix.

Treatment options

(Kumar, Journal of Arthroplasty; 2008

Treatment options


40/53

Plate options:

Less invasive stabilization system (LISS).

Treatment options

(Farouk et al., Journal of Orthopaedic Trauma1999)

Treatment options


41/53

Cortical allograft struts:

Treatment options

(Allan et al.,The Journal of Arthroplasty;

Treatment options


42/53

Revision hip arthroplasty:

Indicated in casesof periprosthetic

fractures with loosefemoral component.

The goal is to by-pass it by at least

two shaft diameters.

Treatment options

Treatment options


43/53

Treatment options

Treatment options


44/53

Revision options:

Cemented long stem implants:

Discouraging results.

Appropriate in the frailelderly patient with

limited functionaldemands and lifespan.

(Sanjeev, Current Orthopaedics; 2006)

Treatment options

Treatment options


45/53

Revision options:

Cementless long stem implants.

Recentlymodularcementless longstem.

Extensive porouscoated.

Long stem with distal

locking screws.

Tapered stems.

Treatment options

(Kwong et al., J Arthroplasty; 2003)

Treatment options


46/53

Revision options:

Proximal femoral replacement:

Post- operative Vancouver B3fractures associated with severe,segmental bone loss

Elderly patients with limited life

expectancy can be treated bytumor-type proximal femoralreplacement prosthesis.

Younger patients the proximalfemoral allograft composite is

recommended.

(Sanjeev, Current Orthopaedics; 2006)

Treatment options


47/53

Revision options:

Impaction Grafting:

High union rate in

revision settings:

With severe osteolysis

or deficient bone stockof the proximal femur.

Together with structural

cortical allograft and orplates.

With long cementedfemoral prostheses.

(Tsiridis et al., Injury 2007)


48/53

Treatment algorithmbased on Vancouver

classification.Intraoperative

fracturesPostoperative

fractures


49/53


50/53


51/53


52/53

Conclusion

Management of these fractures is oftenparticularly demanding, complex and expensive.In many cases, the surgeon has simultaneouslyto deal with the problems of implant loosening,bone loss and fracture. A systematicunderstanding of the unique characteristics of thedifferent fracture types, of the principles of PFF

treatment and a familiarity with the variousfixation devices, grafts and prosthetic implantsare all of paramount importance.


53/53

Thank you

Modern Techniques in Management of Periprosthetic Femoral Fractures After Total Hip Arthroplasty

Documents

Transcript of Modern Techniques in Management of Periprosthetic Femoral Fractures After Total Hip Arthroplasty