well-aligned stems are repaired with plates. A
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Intraoperative fluoroscopy should be considered during instrumentation of the distal femoral shaft to lessen the chance of cortical perforation.
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Postoperative fractures are best avoided by performing timely revision surgery.
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Proximal osteolytic lesions may be observed in asymptomatic case; however, revision surgery or SG should be done in lesions within 2 cm of stem tip even if asymptomatic.5
combination of unicortical or bicortical screws and cerclage wires are used in case of proximal areas while bicortical screws are used distally. If the distal plate extends to supracondylar region, fixed angle blade plate or dynamic condylar screw offers best fixation.
Fractures distal to femoral stems Fractures occurring below femoral stem are treated without any regard to the implant, if the stem does not show loosening. Nonoperative or internal fixations are used depending on health and activity of patient. In cases of internal fixation, plating is generally preferred.
General principles of management •
Primary considerations in deciding rationale of treatment is whether to treat the fracture operatively or not.
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If an operative approach is warranted, whether to proceed with fracture repair or revision arthroplasty.
Conclusion Periprosthetic fractures in THA lead to considerable morbidity in terms of component fixation, bone loss, and subsequent function. Various risk factors have been identified and should be taken into account. Classification of fractures is important for deciding intervention strategy. Early recognition and appropriate management of fractures are critical. Treatment depends on various factors and could be location-specific. Prevention is best and needs attention of the surgeon to minimize periprosthetic femoral fractures.
References 1. Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res. 2004;420:80-95.
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No single approach is applicable to all cases.
2. Franklin J, Malchau H. Risk factors for periprosthetic femoral fracture Injury. Int. J. Care Injured. 200738,655-60.
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Generally speaking, displaced fractures should be stabilized, and loose stems should be replaced with long stems extending well beyond the fracture.
3. Pike J, Davidson D, Garbuz D, et al. Principles of treatment for periprosthetic femoral shaft fractures around well-fixed total hip arthroplasty. J Am Acad Orthop Surg. 2009;17(11):677-88.
Prevention of periprosthetic femoral fractures •
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Wide surgical exposure is important as it avoids placing excessive force, especially torque, on the femur. Deficient bone must be identified prior to surgery and efforts made to avoid further bone damage.
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Implant removal must be done carefully.
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Extended trochanteric osteotomy may be performed to better expose the medullary canal and facilitate cement or prosthesis removal.
6
Perspective
4. Schmidt AH, Kyle RF. Periprosthetic fractures of the femur Orthop Clin North Am. 2002;33(1):143-52. 5. Haddad FS, Masri BA, Garbuz DS, et al. The prevention of periprosthetic fractures in total hip and knee arthroplasty. Orthop Clin North Am. 1999;30(2):191-207. 6. Duncan CP, Masri BA. Fractures of the after hip replacement. Instr Course Lect. 1995;44:293-304. 7. Brady OH, Garbuz DS, Masri BA, et al. The reliability and validity of the Vancouver Classification of femoralfractures after hip replacement. J Arthroplasty. 2000;15:59-62. 8. Tsiridis E, Haddad FS, Gie GA. The management of periprosthetic femoral fractures around hip replacements. Injury. 2003:34:95-105. 9. Fink B, Fuerst M, Singer J. Periprosthetic fractures of the femur associated with hip arthroplasty. Arch Orthop Trauma Surg. 2005; 125(7):433-42. 10. Logel KJ, Lachiewicz PF, Schmale GA, et al. Cortical strut allografts for thr treatment of femoral fractures and deficiencies in revision total hip arthroplasty. J South Orthop Assoc. 1999;8:163-72. 11. Kyle RF, Crickard GE III. Periprosthetic fractures associated with total hip arthroplasty. Orthopedics. 1998;21:982-84. 12. Mont MA, Maar DC. Fractures of the ipsilateral femur after hip arthroplasty: A statistical analysis of outcome based on 487 patients. J Arthroplasty. 1994;9:511-19. 13. Beals RK, Tower SS. Periprosthetic fractures of the femur: An analysis of 93 fractures. Clin Orthop.1996;327:238-46.
Periprosthetic femoral fractures after total hip arthroplasty