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Clinical Scenario
Peri-Prosthetic Fracture

Scenario

A 77-year-old male presents with a fall onto his left hip pain, he was unable to mobilise and has been brought in by ambulance, he is haemodynamically stable. 

Peri-prosthetic Fracture

Interview Questions

Please interpret the radiograph and tell me what you are concerned about in this patient?

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An AP radiograph is presented of the left hip in a 77-year-old female. There is evidence of periprosthetic femoral fracture surrounding a cemented stem with significant displacement. I would want further orthogonal imaging with a lateral hip radiograph and an AP + lateral full length femur radiograph.

 

Key Concerns

  1. Fall Mechanism - ATLS Principles

  2. Exclude open / NV injury

  3. Exclude compartment syndrome

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How would you manage this patient?

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ATLS

“This patient has a potential high energy injury mechanism; I would therefore ensure that the patient was managed via ATLS principles. With a trauma call, introduction of team members and assignment of roles followed by a primary and secondary survey to identify and treat any life / limb threatening injuries.”

 

History

  • Allergies

  • Medication

  • Past medical history

  • Last ate

  • Events

    • Mechanism of injury

    • Social History - nursing home / care home resident?

    • Mobility

    • AMTS

    • Implant related questions

      • Which Hospital?

      • Which Surgeon?

      • What Prosthesis? (Implants requiring special kit for removal / revision)

 

Examination

  • Deformity of limb on inspection

  • NV Intact

  • Open injury?

  • Compartment syndrome - ensure compartments soft

 

Investigation

  • Pre-operative work up: Bloods / CXR / ECG

  • XR: AP Pelvis / AP + Lateral Hip / Full length Femur

  • CT Pelvis: helps to further define fracture pattern

 

Management

  • Analgesia + regular medications

  • Thomas Splint + Skin Traction

    • Check NV status post application

    • Check XR in Traction

  • NBM

  • VTE

  • Add patient to trauma list

  • Inform arthroplasty surgeon who performed operation

  • Obtain further information regarding prosthesis component details

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Note: Peri-prosthetic fracture patients should be optimised for theatre and revised by a specialist hip surgeon

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What classification system can be used for peri-prosthetic total hip replacement (THR) fractures?

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Vancouver Classification [1]

 

Used to classify fractures around the femoral stem. Based on fracture site, stability of the stem and quality of surrounding bone stock.

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Vancouver A (Trochanteric region – above stem)

  • AL = Lesser Trochanter

  • AG = Greater Trochanter

 

Vancouver B (Around stem)

  • B1 = Stem well fixed

  • B2 = Stem loose, good surrounding bone stock

  • B3 = Stem loose, poor surrounding bone stock

 

Vancouver C (distal to tip of stem)

  • Fracture of femoral shaft below the tip of a stable implant

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How does this classification system guide management?

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The Vancouver classification  can be used to guide management:

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  • Vancouver A = conservative management

  • Vancouver B

    • B1 = ORIF (locking plate + cerclage cables)

    • B2 = Revision of femoral component to long stem femoral implant

    • B3 = As above / proximal femoral replacement

  • Vancouver C = ORIF (locking plate + cerclage cables)

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When can peri-prosthetic fractures occur?

 

Intra-operatively / post-operatively

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Intra-operative Fractures

  • Occur during stem insertion

  • More common with uncemented implants

  • Lack of stress-relaxation causes fracture of femoral cortex 

  • These will be treated intra-operatively (e.g. with cerclage wires) 

 

Post-operative fractures

  • Low energy trauma

  • Related to existing stress riser

    • Loose stem / cement mantle / loose cup

  • Becoming more commonplace due to increasingly elderly poopulation and large numbers of THAs performed in UK

 

What is the difference in presentation between uncemented and cemented stems?

 

Uncemented Stems

  • Fracture more commonly

  • Tend to occur earlier

  • Due to stress risers during reaming / broaching

  • And press-fit design

 

Cemented Stems

  • Fracture less commonly

  • Tend to occur later

  • Most commonly fracture around the tip of the prosthesis

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Note: In general uncemented stems are offered to younger patients <65 years with good bone stock and lower risk of fracture when inserted

Remember that all NOF#s should have a cemented stem to reduce risk of peri-prosthetic fracture at insertion

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References

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[1] Rayan F, Dodd M, Haddad FS. European validation of the Vancouver classification of periprosthetic proximal femoral fractures. J Bone Joint Surg Br. 2008;90:1576-1579

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