Unified Classification System (UCS) for peri-prosthetic fractures (PPFx)

Transcription

1 Unified Classification System (UCS) for peri-prosthetic fractures (PPFx) Waleed A Abdulwahid Consultant surgeon Medical City, Iraq 6th Emirates International Orthopedic Congress Dubai, UAE May 3-5, 2018

2 Learning outcome Outline the importance of PPFx Explain the rationale behind UCS classification Discuss reliability & validity

3 Introduction An increasingly common complication of TJA. Third Most Common Cause of Revision.

4 Incidence Increasing Increasing patient longevity more demanding activity % % %

5 Summary of the Published Incidence/Prevalence of Periprosthetic Fractures Associated With Total Hip Arthroplasty (THA) Musculoskeletal Key Periprosthetic Fracture, Prevention/Diagnosis/Treatment Christopher R. Gooding, Donald S. Garbuz, Bassam A. Masri and Clive P. Duncan

6 Etiology Trauma Usually trivial incident Low energy type Osteoporosis Stress Risers in bone

7 Risk Factors Stress risers Previously bone window Prior perforations/screw holes Congenital bowing Prior osteotomy or fractures Osteolysis Loose implant

8 It happens in Osteoporotic bone Fragile soft tissue Fragile bone Fragile patient No place for fragile surgery

9 Outcome of PPFx High risk of complications 14 (31%) complication 6 NU, 6 infection, 2 Loosening Beaule et al High rate of NonUnion. Hoffman et al 2016 High Mortality rate: 11% / 1 st year Bhattacharyya

10 Case 88 y old F Femoral neck fracture

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12 2 days later

13 2.5 months later

14 Difficult to manage. Poor Outcome Careful evaluation of the patient 1. Comorbidities 2. Activity level Careful evaluation of the fracture itself 1. Classification 2. Algorithmic management

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18 Unified Classification System (UCS) Duncan, Haddad The UCS is alphabetical in its core design for ease of application Core principles 1. The location of the fracture 2. The fixation of the component 3. The adequacy of the bone stock and bone strength supporting the implant

19 Voncouver classification Duncan CP, Masri BA. Fractures of the Femur after hip replacement. Instr Course Lec. 1995; 44:

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21 Location: Joints/Bones I: Shoulder II: Elbow III: Wrist IV: Hip V: Knee VI : Ankle For the identification of the bones, the numbering follows that of the AO/OTA Fracture and Dislocation 1:Humerus 2: Forearm 3: Femur 4: Leg 6: Pelvis 7: Hand 8: Talus

22 Types A: Apophyseal B: Bed of Implant C: Clear of implant D: Dividing the bone between two implant E: Each of two bone supporting one arthroplasty F: Facing and articulating with hemiarthoplasty For simplicity, Type, Bone, Joint Type A of the patella associated with knee replacement Type B2 of the femur associated with hip replacement

23 Bone Quality, Fixation Good bone No loosening Good bone Loosening Poor bone Loosening

24 Type A - apophyseai or extraarticular/perlarticular Adjacent to implant, little effect on stability This category would include such examples as: The tuberosities of the humerus The humeral epicondyles or olecranon tip at the elbow The trochanters and epicondyles of the femur The spinous extraarticular pelvic fractures The poles or tips of the patella The tibial tuberosity as well as the malleoli. The need for surgical management would be based on the location and characteristics of each fracture type

25 Type B-bed of the implant or around the implant Bl Good bone, no implant loosening B2 Good bone With implant loosening B3 Poor bone or bone defect with implant loosening Distinction between B2 and B3 is one of individual interpretation, without a clear-cut transition

26 Type c-clear of or distant to the Implant quite distant to the arthroplasty the modern principles of fracture management apply, with little influence brought to bear by the preexisting joint replacement. some type of modified fixation may have to be taken into consideration, (cerclage wires, cables, or mono-cortical screws).

27 Type D - dividing the bone between two implants. interprosthetic or intercalary Quite uncommon as the fracture involves a long bone that supports two prostheses, both proximal and distal to the fracture site Aapproaching type D fractures by separate analyses of implant stability as well as the available bone stock around each of the implants. Treatment should be based upon those separate analyses. Appropriate treatment may involve revision of one, both, or neither arthroplasty.

28 Combinations of Fractures Separate analyses Type D interprosthetic or intercalary fracture, together with the Type B3 periprosthetic fracture with severely compromised bone stock Type E polyperiprosthetic fractures Represent the three most challenging groups of fractures.

29 Type E Type E fracture involving both sides of a joint replacement, ex. with a periprosthetic fracture of the acetabulum and femur. Separate analyses reveal a type B3 fracture of the acetabulum and B2 fracture of the femur.

30 Type F-facing and articulating with - hemiarthroplasty the principles of management.. will depend on the Degree of fracture displacement Health of the articulation, ie, whether it was degenerated prior to the most recent injury.

31 Reliability & Validity of UCS The goal of any classification system is ultimately to improve patient outcome. To be able to accomplish this goal, guide treatment the classification must... be reliable, and valid

32 Reliability & Validity of UCS Field testing the Unified Classification System for periprosthetic fractures of the femur, tibia and patella in association with knee replacement: An international collaboration. M Van der Merwe, J & S Haddad, F & P Duncan, C. Bone & Joint Journal, 96-B(12): December 2014 The UCS has substantial inter-observer reliability & near perfect intra-observer reliability when used for PPFx associated with knee replacement in the hands of experienced & inexperienced

33 Reliability & Validity of UCS The reliability and validity of the Unified Classification System of periprosthetic femoral fractures after hip arthroplasty the UCS for periprosthetic femoral fracture is reliable. JF Huang et al. Acta Orthop. Belg., 2016, 82, Intraobserver and interobserver agreement was judged to be substantial to almost perfect. the validity assessment for type B fracture subgroups showed a substantial agreement. But failed to achieve perfect agreement

34 Implant fracture 1. Alone : revision 2. Bone fracture : revision + fixation/reconstruction

35 51 ys male Acute pain. bedridden AG? B1? Stability Bone stock

36 Question Revision with ETO B1 B2?

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38 1 year

39 Take home A reliable & valid classification system helps to: better understand the problem, construct a treatment algorithm, Maximize the chances of success. Preoperative planning is essential, but..!! must have the flexibility to change the plan should circumstances change during the course of surgery.