Introduction to Periprosthetic Fractures
Assessment of Periprosthetic Fractures
Injury Mechanisms for Periprosthetic Fracture
Injuries Associated with Periprosthetic Fractures
Signs and Symptoms of Periprosthetic Fractures
Imaging and Other Diagnostic Studies for Periprosthetic Fractures
Outcome Goals and Outcome Measures for Periprosthetic Fractures
Periprosthetic Acetabular Fractures
Incidence, Risk Factors, and Prevention of Periprosthetic Acetabular Fractures
Classification of Periprosthetic Acetabular Fractures
Management Principles for Periprosthetic Acetabular Fractures
Preoperative Planning for Management of Periprosthetic Acetabular Fractures
Positioning and Surgical Approach for Management of Periprosthetic Acetabular Fractures
Surgical Technique for Management of Periprosthetic Acetabular Fractures
Potential Pitfalls and Preventative Measures for Management of Periprosthetic Acetabular Fractures
Outcomes for Periprosthetic Acetabular Fractures
Author’s Preferred Treatment of Periprosthetic Acetabular Fractures
Periprosthetic Femur Fractures about Hip Arthroplasty Prostheses
Incidence, Risk Factors, Prevention, and Mortality for Periprosthetic Femur Fractures About Hip Arthroplasty Prostheses
Classification of Periprosthetic Femur Fractures About Hip Arthroplasty Prostheses
Management Principles for Periprosthetic Femur Fractures
ORIF of Periprosthetic Femur Fractures
Revision Arthroplasty of Periprosthetic Femur Fractures
Outcomes of Periprosthetic Femur Fractures
Author’s Preferred Treatment of Periprosthetic Femur Fractures about Hip Arthroplasty Stems
Periprosthetic Distal Femur Fractures about Total Knee Arthroplasty
Incidence, Risk Factors, Prevention, and Mortality for Periprosthetic Distal Femur Fractures
Classification of Periprosthetic Distal Femur Fractures
Nonoperative Management of Periprosthetic Distal Femur Fractures
Principles for Operative Treatment of Periprosthetic Distal Femur Fractures
ORIF of Periprosthetic Distal Femur Fractures
Surgical Approach(es) for ORIF of Periprosthetic Distal Femur Fractures
Intramedullary Nailing of Periprosthetic Distal Femur Fractures
Revision Total Knee Arthroplasty for Periprosthetic Distal Femur Fractures
Author’s Preferred Treatment of Periprosthetic Distal Femur Fractures
Periprosthetic Patella Fractures
Incidence, Risk Factors, and Prevention of Periprosthetic Patella Fractures
Classification of Periprosthetic Patella Fractures
Management of Periprosthetic Patella Fractures
Outcomes for Periprosthetic Patella Fractures
Potential Pitfalls and Preventative Measures for Periprosthetic Patella Fractures
Author’s Preferred Treatment of Periprosthetic Patella Fractures
Periprosthetic Proximal Tibia Fractures
Incidence, Risk Factors, and Prevention of Periprosthetic Proximal Tibia Fractures
Classification of Periprosthetic Proximal Tibia Fracture
Management of Periprosthetic Proximal Tibia Fractures
Outcomes for Periprosthetic Proximal Tibia Fractures
Potential Pitfalls and Preventative Measures for Management of Periprosthetic Proximal Tibia Fractures
Author’s Preferred Treatment of Periprosthetic Tibia Fractures
Periprosthetic Fractures about Ankle Arthroplasty
Incidence, Risk Factors, and Prevention of Periprosthetic Fractures About Ankle Arthroplasty
Management and Outcomes of Periprosthetic Fractures About Ankle Arthroplasty
Author’s Preferred Treatment of Periprosthetic Fractures about Ankle Arthroplasty
Periprosthetic Fractures about Shoulder Arthroplasty
Incidence, Risk Factors, and Prevention of Periprosthetic Fractures About Shoulder Arthroplasty
Classification of Periprosthetic Fractures About Shoulder Arthroplasty
Management of Periprosthetic Fractures About Shoulder Arthroplasty
Outcomes for Periprosthetic Fractures About Shoulder Arthroplasty
Potential Pitfalls and Preventative Measures for Treatment of Periprosthetic Fractures About Shoulder Arthroplasty
Author’s Preferred Treatment of Periprosthetic Fractures about Shoulder Arthroplasty
Periprosthetic Fractures Elbow Arthroplasty
Incidence, Risk Factors, and Prevention of Periprosthetic Fractures About Elbow Arthroplasty
Classification of Periprosthetic Fractures About Total Elbow Arthroplasty
Management of Periprosthetic Fractures About Elbow Arthroplasty
Outcomes for Periprosthetic Fractures About Total Elbow Arthroplasty
Author’s Preferred Treatment of Periprosthetic Fractures about Elbow Arthroplasty
Special Circumstances, Expected Adverse Outcomes, and Unexpected Complications for Periprosthetic Fractures
The optimal treatment of periprosthetic acetabular fractures is primarily dictated by component stability and fracture pattern stability (Fig. 23-1). In the setting of a stable component, stable fracture patterns are generally treated nonoperatively with protected weight bearing. Fracture patterns of this type include non- or minimally displaced anterior column fractures, fractures of the iliac wing, or medial wall fractures. Close follow-up, with weekly or biweekly radiographs are used to confirm progressive healing without secondary loss of reduction. Weight bearing is increased at about 6 weeks based on clinical and radiographic evidence of fracture healing.
Surgical treatment with ORIF is preferred for management of unstable fractures about a stable acetabular component. Typical patterns of bony injury encountered in this scenario are displaced posterior column or transverse fractures. The fixation strategy, surgical approach, and implants are dictated by the details of the fracture pattern and generally follow those utilized for treatment of native acetabular fractures. Adjuvant bone grafts in these situations are generally not indicated.
In the setting of an unstable acetabular component, treatment requirements become much more complex. In such cases when there is a stable fracture pattern, revision of the acetabular component may be all that is required. In such cases, revision of the acetabular component with a press-fit shell utilizing multiple screw fixation on either side of the fracture may serve to provide a stable component as well as help stabilize the fracture. When the periprosthetic fracture involves both an unstable component and an unstable fracture pattern, the degree of bone loss should also be considered in the treatment algorithm. When there is no substantial bone loss, fixation of the unstable acetabular fracture as well as revision of the loose acetabular component is recommended. This usually takes the form of plating of the posterior column of the acetabulum. Revision also includes use of multiple screws preferably on either side of the major fracture line. In the setting of a pelvic discontinuity, reconstruction of the columns of the acetabulum may require substantial structural bone grafting with the possibility of the use of an acetabular cage. These cases represent some of the most challenging acetabular revisions and should be undertaken by an experienced surgical team with a substantial amount of necessary resources available.
We find the Vancouver classification very useful in determining treatment for periprosthetic femoral shaft fractures (Fig. 23-20). Nondisplaced Vancouver A fractures are generally treated nonoperatively with protected weight bearing based on comfort unless the fracture is noticed intraoperatively. In such cases, we have a lower threshold for cable or claw plate fixation. Widely displaced Vancouver A fractures are generally treated with ORIF with a claw plate and cables.
Vancouver B1 fractures are usually treated with ORIF via a lateral approach. These fractures are typically simple spiral patterns and we prefer to use cables to help obtain and maintain a provisional reduction. Fixation is with a lateral locked plate which is secured proximately with cables and then with locked screws into the trochanteric region. Distal fixation is with a combination of nonlocked and locked screws depending upon the bone quality. Lag screws are placed across the fracture through the plate whenever feasible. We prefer to protect the entire length of the femur and therefore select a plate that extends at least to the distal metaphyseal flare and we usually utilize a distal femoral locking plate. Comminuted fractures are treated similarly except a bridge plating technique is utilized. We neither generally utilize any bone grafts for Vancouver B1 fractures nor do we perform revision arthroplasty for well-fixed stems.
By definition, Vancouver B2 fractures have a loose stem and therefore our treatment incorporates revision of the femoral component. However, in select cases when the patient’s functional demands are severely limited, and when the patient had no preoperative symptoms associated with the loose prosthesis, we may forgo revision arthroplasty especially if the patient has substantial cardiopulmonary comorbid disease that increases the risk of intraoperative or postoperative medical complications. In most cases, we perform revision arthroplasty with bowed noncemented stems across the fracture. We also generally supplements revision arthroplasty with a long lateral plate that protects the entire femur from future fracture. If there are bone defects, these are managed with structural allograft in addition to the lateral plate.
Vancouver B3 fractures present substantial technical challenges. We highly recommend these fractures be placed in the hands of a surgeon that is well versed with revision hip arthroplasty technique as well as proximal femoral replacement technique. As with other types of periprosthetic femur fractures, we typically protect the entire femur with a lateral plate after revision arthroplasty.
We treat Vancouver C fractures according to the techniques outlined for plate and screw treatment of distal femur fractures. Typically, a lateral lock plate is utilized. We are careful to use plates long enough to overlap the femoral stem such that two cables can be placed that are spaced apart by 3 to 4 cm.
As with most periprosthetic fractures, the typical first branch of the decision tree is at the determination of the stability of the existing prosthesis (Fig. 23-29). When a distal femur fracture involves an associated loose prosthesis, revision arthroplasty is indicated. Because of the paucity of critical soft tissue attachments in this anatomic region, distal femoral replacement is our treatment of choice for these fractures. These prostheses provide adequate stability through their built-in constraint mechanisms and their insertion is technically straightforward for the surgeon practiced in this technique. They allow immediate weight bearing and therefore early rehabilitation, and they have reasonable outcomes. The longevity and complication rates associated with distal femoral replacement, however, do not favorably compare with fracture fixation of distal femoral fractures about stable implants.
ORIF and IMN both are reasonable options for the management of distal femur fractures about stable and well-functioning femoral components. The decision for one or the other is based on fracture fragment size, the morphology of the femoral arthroplasty component, and surgeon’s preference. When the distal fracture fragment is so small that control of it with a retrograde nail is suspect, ORIF is indicated. We reserve IMN for cases where the distal fragment extends into the diaphyseal region but we recognize that it is reasonable to consider this option anytime the distal fragment is at least long enough to allow placement of two to three distal interlocks. Another absolute requirement for IM nailing is the presence of a prosthesis with an open intercondylar notch. Lateral locked plate fixation is our preferred method for any fracture confined to the distal metaphyseal region, even fractures that extend beyond the confines of the anterior flange of the femoral component. Our results of ORIF of extreme distal fractures are similar to results for more proximal fractures with larger distal fragments. However, in certain individual cases, we consider distal femoral replacement for these extreme distal fractures.
Patella fractures are among the most difficult periprosthetic fractures to manage (Fig. 23-31). Operative management is associated with relatively high nonunion and infection rates and nonoperative management may require prolonged immobilization and does not address loose components. We tend to lean toward nonoperative management for these fractures unless displacement is severe or the component is so loose that it may dislodge. A staged management protocol that treats a periprosthetic patella fracture associated with a loose component sequentially rather than simultaneously is sometimes prudent to avoid major complications. Nonoperative fracture management to healing followed by surgical management of a loose component, if symptomatic, is a strategy that takes longer to complete but may ultimately result in fewer complications. When acute operative management is undertaken in the face of a stable component, we have a low threshold for excision of small- to moderate-sized superior or inferior pole fragments with suture repair of the associated tendon to the remaining bone. Patellectomy is our operative treatment of choice for cases with a loose prosthesis and poor bone stock.
Fortunately, periprosthetic tibia fractures around TKAs are relatively uncommon (Fig. 23-37). When they do occur, most often they are associated with a loose tibial component; therefore revision is preferred in these situations. Tibial revision for periprosthetic fracture requires the routine use of stems and augments and metaphyseal-filling metal implants can be useful for managing bone deficiencies. The tibial base trays have often subsided into varus, and anticipating medial and central defects is wise. The surgeon should be aware that isolated tibial component revision is rare, and commonly, one should be prepared to revise the entire arthroplasty.
When the tibial component is stable and the fracture displaced, our preferred method of treatment is with lateral locked plates. Although there is scant literature supporting this or any other practice for these fractures, it is our feeling that locked plates are invaluable for these fractures. The amount and quality of bone proximally is usually marginal and in these situations nonlocked screws rarely obtain adequate fixation. Locked screws proximally and either locked or nonlocked screws distally through a lateral plate may provide sufficient stability. We, however, have a low threshold to supplement a lateral plate with a posterior-medial locked plate (Figs. 23-33 and 23-34). Medial comminution and an inability to pass lateral screws across to the medial side are indications for dual plating. It is critical that these exposures be through separate incisions so as to maximally preserve the soft tissue envelope. Even in the presence of a midline incision from the TKA, separate lateral and medial incisions can provide an adequate skin bridge in all but the thinnest of patients.
Periprosthetic ankle fractures are uncommonly dealt with, except by those surgeons who perform a high volume of TAAs, especially since the majority of these fractures occur intraoperatively (Fig. 23-39). When an intraoperative fracture is encountered, ORIF is preferred, except for the most minimally displaced fracture, to maximize stability of the arthroplasty. Postoperative fractures about stable implants are treated operatively with ORIF when the fracture potentially affects joint stability or when displacement is great enough to risk nonunion with nonoperative treatment.
Management of periprosthetic humeral fractures about shoulder arthroplasty stems is relatively straightforward and is based on the stability of the stem and the displacement of the fracture (Fig. 23-43). Most of these fractures occur about stable stems so revision arthroplasty is rarely required. Nondisplaced or minimally displaced fractures are managed nonoperatively with a fracture brace, similar to a native humeral shaft fracture, one that is not associated with a prosthesis. The indications for operative treatment are also similar to native humeral shaft fractures although the threshold for recommending operative treatment is somewhat lower. As opposed to native fractures that can be treated with either IMN or ORIF, operative treatment of periprosthetic fractures is limited to ORIF. A posterior approach is preferred to allow direct visualization and protection of the radial neurovascular bundle. A posterior large fragment plate is secured proximally with cables and distally with screws. Locked screws are utilized when osteoporotic bone is encountered.
Decision making for treatment of periprosthetic fractures about an elbow arthroplasty is relatively straightforward (Fig. 23-46). Diaphyseal fractures, or either the humerus or ulna, associated with a stable prosthesis are managed with ORIF. The preferred approach to the humeral shaft is posterior so that the radial and ulnar nerves can be directly visualized and protected. Passing cables from an anterior approach puts the radial nerve at substantial risk for injury given its immediate proximity to the posterior humeral cortex. Passing cables from posterior does not put the median nerve at such high risk as the median nerve is not in such close approximation to the anterior bone. Even when the prosthesis stem crosses the fracture, adjunctive ORIF is recommended. This is because long-stemmed humeral components are not canal filling and therefore provide little stability to the fracture. Long-stemmed ulna components provide marginal stability because they are typically either very thin or barely cross the fracture. Bone loss is managed with strut allografting. When diaphyseal fractures of either the humerus or ulna are associated with a loose component, revision arthroplasty is indicated.
A special circumstance relates to periprosthetic metaphyseal fractures of the distal humerus. Management of these fractures considers the prosthesis type. Constrained or semiconstrained prostheses do not rely on ligamentous stability, so the epicondyles are not critical to prosthesis function. Therefore, metaphyseal fractures involving the epicondyles can often be treated nonoperatively, even if displaced. If displacement is so great that there is concern for nonunion, then ORIF is indicated. When these fractures occur around an unconstrained prosthesis, reduction and fixation is generally performed to restore ligamentous stability.