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Treatment of Periprosthetic Femoral Fractures after Hip Arthroplasty

Article information

J Musculoskelet Trauma. 2020;33(1):43-51
Publication date (electronic) : 2020 January 23
doi : https://doi.org/10.12671/jkfs.2020.33.1.43
Jung-Hoon Choi, M.D.orcid_icon, Jong-Hyuk Jeon, M.D.orcid_icon, Kyung-Jae Lee, M.D.orcid_icon
Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea.
Correspondence to: Jong-Hyuk Jeon, M.D. Department of Orthopedic Surgery, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu 42601, Korea. Tel: +82-53-258-4770, Fax: +82-53-258-4773, dream21jh@naver.com
Received 2020 January 04; Revised 2020 January 06; Accepted 2020 January 06.

Abstract

Although the incidence of postoperative periprosthetic femoral fractures after hip arthroplasty is expected to increase, these complex fractures are still challenging complications. To obtain optimal results for these fractures, thorough clinical and radiographic evaluation, precise classification, and understanding of modern management principles are mandatory. The Vancouver classification system is a simple, effective, and reproducible method for planning proper treatments of these injuries. The fractures associated with a stable femoral stem can be effectively treated with osteosynthesis, though periprosthetic femoral fractures associated with a loose stem require revision arthroplasty. We describe here the principles of proper treatment for the patients with periprosthetic femoral fractures as well as how to avoid complications.

Keywords: Femur; Periprosthetic fracture; Hip arthroplasty; Vancouver classification

Notes

Financial support

None.

Conflict of interests

None.

References

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Copyright © 2020 The Korean Fracture Society. All rights reserved.
The Korean Fracture Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Fig. 1

Fig. 1

(A) Preoperative radiograph and computed tomography scan show a periprosthetic femoral fracture after revision total hip arthroplasty. The surgeon decided the stem to be stable (Vancouver type-B1). (B) Indirect reduction with locking plate fixation was applied for this patient. Note that a locking attachment plate and cables were used for additional stability. (C) Postoperative radiograph at three months shows subsidence of the femoral stem (Vancouver type-B2).

Fig. 2

Fig. 2

Anteroposterior radiographs of the femur obtained at prefracture (A) and post-fracture (B). Note that the distance between the tip of the greater trochanter and stem shoulder was increased after the periprosthetic fracture (stem subsidence). This implies the stem is unstable.

Fig. 3

Fig. 3

(A) The preoperative radiograph shows periprosthetic femoral fracture. This stem is classified as type 1, which means it is a single-wedge proximal coated stem. Note that the fracture itself did not involve the proximal coating area. Open reduction and internal fixation with a locking plate (absolute stability) was applied (B) and the radiograph obtained at 5 years after fixation (C) shows a well-united fracture site and stable stem.

Fig. 4

Fig. 4

Postoperative radiographs shows use of a blunt tip screw (arrow) to avoid cement mantle damage.

Fig. 5

Fig. 5

(A) A 79-year-old female sustained a Vancouver type-AG fracture (arrows) after a fall. (B, C) A greater trochanteric fragment was displaced and recurrent dislocation had developed. (D) Open reduction and internal fixation with a claw plate was applied.

Fig. 6

Fig. 6

Anteroposterior and lateral radiographs of the femur show a long looking plate was used for the Vancouver type-B fracture. Six unicortical screws and two cables were applied on the proximal femur for achieving sufficient stability.

Fig. 7

Fig. 7

(A) Preoperative radiographs of the femur show a minimally displaced Vancouver type-B fracture. (B) Indirect reduction with plate osteosynthesis (relative stability) was used for the fixation.

Fig. 8

Fig. 8

(A) Preoperative radiograph of the femur shows a Vancouver type-B2 fracture. (B) Postoperative radiograph shows revision of the femoral stem with using a prophylactic cable (arrow).

Fig. 9

Fig. 9

(A) A 45-year-old male sustained a comminuted Vancouver type-C fracture after a traffic accident. (B, C) Minimally invasive plate osteosynthesis with a locking plate was used and the radiograph demonstrates good healing of the fracture.

Table 1

Vancouver Classification of the Postoperative Periprosthetic Femoral Fractures

Classification Site of fracture(s) Sub-classification
Type-A Trochanteric region AG: greater trochanter
AL: lesser trochanter
Type-B Adjacent or just distal to the femoral stem B1: well-fixed prosthesis
B2: loose prosthesis
B3: loose prosthesis with poor residual bone stock
Type-C Distal to the femoral stem