Osteosynthesis in periprosthetic fractures: Indications, tips, and tricks


Currently, most periprosthetic femoral fractures (PPFF) are surgically managed. In treating PPFF, the first and a crucial decision facing the surgeon is: Is osteosynthesis or revision arthroplasty indicated for my patient? Although the current literature does not provide a black and white picture of which patients require stem revision and which require internal fixation only, correct assessment of the stability of the prosthetic implants greatly assists the decision-making process.


It is generally accepted that, in case of a simple fracture type with stable stem, osteosynthesis can be an effective management. However, a loose stem can easily be misdiagnosed as a stable stem, forcing the surgeon to change the treatment plans intraoperatively, since fracture fixation of a loose stem often results in a painful and unsatisfactory condition for the patient. In this article, Karl Stoffel, Chief Physician at the Bethesda Hospital, University Hospital Basel, will first focus on the process of diagnosing a loose stem in the Vancouver types of fractures and then share some general principles as well as some tips in performing osteosynthesis in PPFF. Since the Unified Classification System fracture types D, E, and F are rare, complicated, and have little supporting evidence in the literature, these will not be covered here.

Karl Stoffel

Chief Physician
Bethesda Hospital
University Hospital Basel, Switzerland


The Unified Classification System (UCS) expanded upon the Vancouver Classification system and in combination with the AO/OTA Fracture and Dislocation Classification, covers all periprosthetic fractures. The UCS fracture types are:
A, Apophyseal
B, Bed of the implant
C, Clear of the implant
D, Dividing the bone between two implants
E, Each of two bones supporting one joint replacement
F, Facing and articulating with arthroplasty

Screenshot from: Velkes S, Stoffel K. Periprosthetic fractures around the hip. In: Schutz M, Perka C, ed. Osteoporotic Fracture Care—Medical and Surgical Management. Stuttgart: Thieme; 2018. 461–478.

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Stable or loose: How can we decide?

In deciding the stability of the implant, many factors must be considered. Among these are patient-specific factors, fracture patterns, and injury history. To ensure that all essential factors are considered, Karl Stoffel describes an algorithmic approach (Figure 1) that helps surgeons systematically evaluate the fractures using tools that are easily available, such as the patient history, nature of the fracture, stem design, and plain x-rays.

A history of thigh pain

In case of low-energy trauma, patients do not always recall the actual trauma event and cannot provide any trauma history except for the description of gradually increasing pain.

Should a patient describe increasing thigh pain on weight bearing or reduced mobility due to hip problems prior to the fracture, there is a high possibility that a loose stem is involved [1–3].

Figure 1. An algorithm to better identify loose stems in patients suffering a periprosthetic fracture after total hip replacement. 1) Increasing pain or reduced mobility due to hip problems prior to the fracture could be a sign of stem loosening. 2) Comminution around the stem is a sign of a loose stem. 3) Noncemented stems: i) an intra- or postoperative fracture in the first few weeks is indicative of a loose stem; ii) in the presence of stem subsidence, and iii) significant osteolysis, the stem is most likely loose; iv) if the fracture is at the primary level of fixation, the stem is expected to be loose; v) if the stem is stable intraoperatively, then ORIF should be considered. 4) Cemented stems: i) a fracture around a composite beam-type stem should be considered loose; a polished-taper stem may still be well fixed if the cement mantle is not fragmented or deficient. If the cement mantle is fragmented or deficient, a stem should be considered loose. Source: Stoffel K, et al. Periprosthetic fractures of the proximal femur: beyond the Vancouver classification. EFORT Open Rev. 2020 Jul;5(7):449–456. (CC BY-NC 4.0 license).

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  • Radiographic signs of implant instability
  • Determining the stability of cementless stems
  • Determining the stability of cemented stems
  • Testing stability intraoperatively
  • General management principle: Importance of surgical planning
  • How long should a plate be?
  • How to determine the number of screws and their placement?
  • How to ensure rotational stability and bicortical fixation?
  • Special considerations
  • Conclusion
Additional Resources

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Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):

Baochao Ji

Associate professor
First Affiliated Hospital of Xinjiang Medical University
Urumqi, Xinjiang, China

Cao Li

Professor
President of the Chinese Hip Society and director of the First Affiliated Hospital Xinjiang University
Urumqi, China

Karl Stoffel

Chief Physician
Bethesda Hospital
University Hospital Basel, Switzerland

Luigi Zagra

Head of the Hip Department
IRCCS Galeazzi Orthopaedic Institute, Milan,
and Past President of the European and Italian Hip Societies, Italy

This issue was written by Maio Chen, AO Innovation Translation Center, Clinical Science, Switzerland.

 

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