Introduction

The current overall incidence of periprosthetic

femur fracture is approximately 4.1%, with
higher rates for uncemented and revision THA.
Late periprosthetic fractures account for
approximately 6% of revision cases and are
the third most common reason, after aseptic
loosening and infection, for revision surgery
Historically, nonoperative treatment such as
traction has yielded poor results.
 Diagnosis

A history of pain or dysfunction may indicate prosthetic

loosening or infection.
Conventional radiographs are the workhorse for diagnosis
of periprosthetic fractures. A comparison to older
radiographs is optimal to give the best chance of detecting
loosening. computed tomography may allow further
visualization of fracture lines and provide evidence of
prosthetic loosening.
One study of 204 patients with periprosthetic hip fractures
recorded an elevated white cell count, erythrocyte
sedimentation rate, and C-reactive protein in 16.2%, 33.3%,
and 50.5% of patients, respectively. The true infection rate
in the group was 11.6%
 Classification

Femoral periprosthetic fractures may occur

intraoperatively or postoperatively
The widely used Vancouver classification,
provides a practical assessment of
postoperative femoral fractures according to
the level of the fracture and the presence of a
well-fixed or loose component.
Vancouver Classification of Postoperative
Periprosthetic Femur Fractures
 Vancouver classification description:

Type-A fractures occur within the proximal metaphysis and

are subclassified as AG or AL for fractures around the
greater and lesser trochanters, respectively.
Type-B fractures occur at or just below the distal tip of the
femoral prosthesis and are subclassified as follows:
type-B1 fractures occur around a well-fixed component;
in type-B2 fractures, the component is loose but has sufficient
bone stock for straightforward revision surgery; and
in type-B3 fractures, the component is loose, with substantial
osteolysis and bone loss.
Type-C fractures occur well distal to the stem, so implant
stability is not an issue.
 Using the Vancouver classification, the
Swedish Hip Register reported that more than
80% of periprosthetic fractures are type-B
fractures. For primary stems, approximately
24.5% are stable (type-B1 fractures), and
75.5% are associated with a loose stem (types
B2 and B3).
 Predisposing Factors/Mechanisms of Injury

female gender,
the presence of rheumatoid arthritis,
the presence of large osteolytic lesions
(especially in high-stress anatomical regions
and in younger patients with high activity
levels)
and advanced age, possibly as a result of
osteoporosis.
 Surgical Technique

Results from the Mayo Clinic joint registry

indicated an intraoperative periprosthetic
femoral fracture incidence of 0.3% in 20 859
patients undergoing primary cemented THA
and 5.4% in those undergoing uncemented
THA.
 Metabolic Bone Disease Associated With
Periprosthetic Fracture

Osteoporosis
Vitamin D deficiency
Bisphosphonates are antiresorptive agents and
are now the most commonly used
antiosteoporotic agent. Although this
characteristic may provide a benefit in the battle
against osteoporosis, it potentially slows down
bone healing, although clinical data are sparse.
Parathyroid hormone
 Surgical Management

Vancouver Type-A Fractures:

type AG :depends on the degree of displacement involved.
Type-AG fractures that are minimally displaced and considered stable
have historically been treated nonoperatively with protected weight
bearing or an abduction brace.
Type AG fractures that are displaced fractures that are displaced.
Surgical methods of fixation used have been similar to that described
for trochanteric osteotomy, namely, with wires, screws, cables, or
specialized plate.
Fractures of the lesser trochanter (type AL) are rare and are usually
avulsion fractures occurring through osteoporotic bone or areas of
osteolysis
If the implant is considered stable, nonoperative treatment is
warranted
in the presence of osteolysis, revision surgery with or without bone
graft is required to achieve stem stability
Vancouver Type-B1 Fractures
Nonoperative treatment is no longer
recommended because patients do not
tolerate prolonged immobilization and
increased risk of subsequent complications
such as death, pulmonary infection, and skin
ulceration.
Open Reduction Internal Fixation
Minimally invasive plating and locking plates
 Excessive screws should be avoided
because it creates stiffness and high
fracture stain leading to
nonunion and plate fracture

Marsland, D. & Mears S.C. (2012) Geriatr Orthop Surg Rehabil. 2012 Sep; 3(3):107-20
Figure Modified with permission from Pletka et al.
Vancouver Type-B2 and -B3 Fractures
Cemented revision THA. only 60% of patients had a
stable implant with fracture union.
Long-stem uncemented THA. Uncemented stems tend
to be used in younger patients to preserve bone stock.
Clinical results using a fully coated uncemented stem
are promising. Union rates at medium-term follow-up
range from 83% to 100%.
Bone Graft
Cortical strut grafts and impaction grafting. The major
disadvantage of allograft is the potential for disease
transmission
 Vancouver Type-C Fractures
Surgical techniques include dynamic
compression plates, plates and cerclage wires,
and more recently, nonlocking plates.
Retrograde intramedullary nailing has also
been used
Algorithm for managing Vancouver type-B periprosthetic femur fractures
 Postoperative Recovery and Complications

In general, postoperative recovery remains

unpredictable and the risk of perioperative and
postoperative complications after surgery for
periprosthetic fractur is high
Up to 23% of 1049 patients required reoperation for
late complications, and of the 245 patients in this
group, the most common reasons for reoperation were
nonunion (24%), refracture (24%), aseptic loosening
(21%), and recurrent dislocation (16%).
The mortality rate for periprosthetic femoral fracture is
high.
 Prevention

Given that 70% of patients with periprosthetic

femur fractures have stem loosening and that
complication rates after surgical treatment are
high, it has been suggested that the optimal
approach for such patients is probably surgical
intervention before the patient sustains a
fracture
 Conclusion

Periprosthetic femoral fractures associated

with THA remain difficult to treat. The
reoperation rates are high
Given that outcomes are usually poor, the
prevention of periprosthetic femoral fractures
remains the best strategy
Updates of classification, methods of fixation, revision surgery and outcome
 Unified Classification System for Periprosthetic Fracture

Duncan CP, Haddad FS. Classification. In: Schutz M, Perka C, Ruedi TP, ed. Periprosthetic Fracture Management. Stuttgart and New York: Georg Thieme Verlag, 2013:4789..
 Type A

Apophyseal fracture of the inferior pole of the patella with

disruption of the exterior mechanism
 Type B1

Type B1 of the patella, fracture involving the bed of the implant

without loosening of the component
 Type B3

Type B3 of the tibia Type B3 of the femur

Fracture involving the bed of the implant with Fracture involving the bed of the implant with
loosening and bone loss loosening and bone loss
 Type D

Type D of the femur

Involving a single bone which supports two implants: knee and hip
 Incidence & Risk Factors
Fracture Incidence
Uncommon, complicated only
Patellar
0.68% of 12.000 primary TKA
Rare (0.4 0.7%), can occur
Tibial
peri-or post-operatively
Usually occur in supracondylar
Femoral
region (0.3 2.5%)
Risk & Contributing factor
Trauma, axial malalignment,
excessive resection, lateral release,
damage to blood supply
Malalignment, instability
Trauma, anterior femoral notching,
constrained components, vascular
compromise, infection, knee
ankyloses, previous TKA revision,
prolonged steroid use, OA, RAA,
geriatric, female& neurological
condication
 Principles of Periprosthetic Fracture Management

1. Restoration of axial alignment and length

2. Stable fixation
3. Maintenance of supportive biological environment
4. Early mobilization
 Supracondylar Periprosthetic Fracture

The results of closed treatment of non-displaced

supracondylar periprosthetic fractures vary:
56% (4 out of 7) 1 vs. 83% (25 out of 30) 2
Traditionally it is treated with ORIF best used for
simple, proximal fractures in strong bone using fixed-
angle devices.
Condylar buttress offer less table fixation, risking
nonunion or malunion with varus collapse.
Intramedullary nails shares load & offer maximal
respect of soft-tissue environment.

1. McLaren AC, Dupont JA, Schroeber DC. Clin Orthop Relat Res 1994;302:194198
2. Chen F, Mont MA, Bachner RS. J Arthroplasty 1994;9:521526
 Supracondylar Periprosthetic Fracture

Retrograde nailing is effective for both displaced and

undisplaced spracondylar fx offers stability in the
presence of communution of the medial cortex
Blade-like device which interlocks with nails confers
benefits in stiffness and strength over conventional
locking bolts. 1
Fixed-angle locking is more durable to non-locking
nails which is potentially important in fractures
which are slow to heal. 2

1. Ito K, Hungerbhler R, Wahl D, Grass R. J Orthop Trauma 2001;15:192196

2. Pekmezci M, McDonald E, Buckley J, Kandemir U. Bone Joint J 2014;96-B:114121
 Supracondylar Periprosthetic Fracture

Radiographs showing malunion in a displaced supracondylar

periprosthetic femoral fracture treated with a condylar plate
Indication for Revision in TKA following Periprosthetic Fracture

Absolute Indications Relative Indications

Implant loosening Fracture involving

Insufficient bone pathological lesions
stock for near the implant
osteosynthesis Fracture of
Multiply failed severely
osteosynthesis osteopaenic bone
in frail patients
 Locking Plates vs. Traditional Plates

In the current literature: locking plates have better

results than traditional plates.
Retrograde intramedullary nails offer higher rates of
union & reduced rates of reoperation but may be
prone to higher rates of malunion.
Author Study Analyzed Results
Herrera et al. 29 case series - Retrograde nailing associated with RRR
(415 fractures) of 87% for developing nonunion & 70%
for revision.
- Locking plate RRR 57% for nonunion
and 43% for revisionsurgery.
Restevski et al. 44 studies (719 No significant differences in rates of
fractures) nonunionOR=0.39 or further surgical
procedures (OR=0.65)
1)Herrera DA, Kregor PJ, Cole PA, et al. Acta Orthop 2008;79:2227. 2) Ristevski B, Nauth A, Williams DS, et al. Orthop Trauma 2014;28:307312
 Revision TKA

Chen et al. reviewed 12 studies (195 fractures):

92% (ten out of 11) have high patient satisfaction rates.

Springer et al. reviewed 11 distal femoral replacements (10

nonunion)
81% (n=8) were satisfied with the outcome with a mean
KSS of 75 (44 to 99) at a mean follow-up of 58.5 months.
Nearly a third of the patients, however, had a
complication, the most common being infection
requiring washouts.

Chen F, Mont MA, Bachner RS. J Arthroplasty 1994;9:521526 Springer BD, Sim FH, Hanssen AD, Lewallen DG. Clin Orthop Relat Res
2004;421:181187.
 Conclusion

Periprosthetic knee fracture are challenging

injuries.
Surgeon often faced with elderly patients with
complicating morbidities.
The goal should always be early mobilization.
A need to identify centers and surgeons with
special interest in order to optimize outcomes