PERIPROSTHETIC FEMUR FRACTURES AFTER THA: Treatment with Revision
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1 PERIPROSTHETIC FEMUR FRACTURES AFTER THA: Treatment with Revision Daniel J. Berry, MD LZ Gund Professor Department of Orthopedic Surgery Mayo Clinic Rochester, MN
2 Presenter Disclosure Information The author has received royalties from DePuy related to certain hip products The author s institution receives research support from: DePuy, Zimmer, Stryker, Biomet, Smith-Nephew
3 Introduction The infrequency and complexity of these problems often leads to suboptimal management
4 Introduction Fortunately We don t see much of this anymore:
5 Introduction But we still see this Nonunion
6 Introduction And we still see this Loose
7 Current Management?
8 Vancouver Classification Fracture Location Guides Treatment: Peritrochanteric Around stem Well distal to stem
9 Fractures Around Stem: Fractures Around Stem Little role for nonoperative Rx Prolonged recovery Just delays--and makes more difficult--the inevitable operation Risk of malunion, nonunion
10 Non Operative Treatment: Problems Malunion Non union
11 Fractures Around Stem Fracture Around Stem Stem Fixed Stem Loose Stem Loose Bone Poor ORIF Revise Revise
12 Loose Stem Fracture Around Stem Stem Fixed Stem Loose Stem Loose Bone Poor ORIF Revise Revise
13 Loose Stem Revision Principles: Use fracture for access to remove implant Bypass fracture, usually with long stem Stabilize fracture Get stable implant fixation Respect biology: Avoid stripping muscle
14 PERIPROSTHETIC FEMUR FRACTURES: Vancouver B 2 /B 3 Fractures Around Loose Stems: With modular tapered fluted, modular stems we can treat B 2 and B 3 fractures the same!
15 Preop 3 Months
16 PERIPROSTHETIC FEMUR FRACTURES: Vancouver B 2 /B 3 Bypass fracture with fluted tapered stem get distal axial and rotational stability Reassemble fracture around proximal stem as scaffold
17 PERIPROSTHETIC FEMUR FRACTURES: Vancouver B 2 /B 3 Key points: Access failed implant and joint through fracture or osteotomy Keep all fracture fragments vascular Goal: Reasonable but not anatomic reduction
18 PERIPROSTHETIC FEMUR FRACTURES: Vancouver B 2 /B 3 Keys to Success: Absolute axial and rotational stability distal to fracture Ream distal femur aggressively Prophylactic cerclage below fracture
19 PERIPROSTHETIC FEMUR FRACTURES: Vancouver B 2
20 PERIPROSTHETIC FEMUR FRACTURES: Vancouver B 2
21 PERIPROSTHETIC FEMUR FRACTURES: Vancouver B 3 Fracture Postop 2 yrs 2 yrs
22 PERIPROSTHETIC FEMUR FRACTURES: Results Mayo Experience: 44 B 2 /B 3 fxs Healing 43/44 Stable stem 43/44 Vancouver Experience: Similar! Abdel, Lewallen, Berry, CORR 2014;472:599
23 Pitfalls Fracture Immediate postop Avoid Undersizing Stem Loose
24 Pitfalls Preop 2 Years 2 Years Migration of Proximal Bone Fragments
25 PERIPROSTHETIC FEMUR FRACTURES: Conclusions Modern Techniques: Simplified treatment Higher level of success Revision
26 Modern Techniques: Conclusions Emphasis on simultaneously creating strong durable mechanical constructs and Optimizing biologic environment for fracture healing
27 EARLY POSTOP FRACTURES
28 Early Postop Femur Fracture Incidence Has Increased in Recent Years: More wedge shaped uncemented stems Smaller exposures missed intraop fxs Quicker rehab, earlier weight bearing, more falls
29 Etiology of Early Postop Fractures Etiology: Unrecognized intraop fracture that displaces under load Fall or stumble that creates new fracture before stem is bone ingrown
30 Early Postop Femur Fracture Most are associated with uncemented proximally coated wedge shaped stems
31 Fracture Patterns Stereotypical Pattern: triangle of posterior medial cortex with lesser trochanter
32 Fracture Patterns Typical Pattern: Loose Subsided Retroverted
33 Fracture Patterns: Fracture-Dislocation
34 Treatment Remove implant, fix fracture, revise stem Results mostly good
35 Early Fracture Prevention Identify and treat intraop fractures Prophylactic cerclage in selected patients Warn patients on rapid rehab protocols to avoid falls 280 lb male Prophylactic cerclage
36
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