thesis presentation ppt
TRANSCRIPT
Management of Periprosthetic Femoral Shaft Fractures
after Hip Arthroplasty
Presented by
Berhe Gebreslassie KassaMD equivalent to Egypt‘s M.B.B.Ch, (2006)
Faculty of MedicineAddis Ababa University
ACKNOWLEDGEMENT
Prof. Adel Ghazal Prof. Yassin El Ghoul Dr. Sameh Mahmoud Abo El-Fadl
Prof. Masri BA Prof. Duncan CP All members SCUOD MUNDO
Def: It is fracture around the joint replacement prosthesis.
effect ranges from being minor, with minimal or no effect on the outcome, to being catastrophic and possibly creating an unreconstructable problem.
Introduction
now steadily increasing due to increase:
a. number of primary hip arthroplasties - young - active - osteopenic elderly patients b. revision hip arthroplasties c. life expectancy
classified as:
a. Intraoperative PPFs: - occur during the operative
procedure and/or on the postoperative radiograph in the recovery room.
b. postoperative PPFs: - occur outside of this time frame
Incidence
cemented THR uncemented 0.1 - 1% & revision THR
3.6% - 20 %
fracture after THR Primary: 0 - 1.2
% Revision: 4 %
Etiology and Risk factors
low-energy falls High-energy trauma spontaneous fractures
excessive torque during surgical exposure or bone preparation
prosthesis is dislocated cement is removed prosthesis is inserted
decrease in the quality and mechanical strength of the host bone
The common risk factors are categorized into systemic and local risk factors
Systemic Factors: osteopenia, osteoporosis,
rheumatoid arthritis, paget's disease, osteopetrosis, osteogenesis imperfecta, thalassemia, osteomalacia, & neuromuscular disorders
Local Factors: cementless femoral prostheses, complex proximal femoral deformities, revision arthroplasty, & loose femoral prostheses
There are different types but at present the Vancouver classification probably comes closest to the ideal system for clinical practice.
Classification
takes into account the location, pattern, and stability of the fracture
classified as: type A - proximal metaphysis type B - diaphyseal type C - distal to the stem
tip Each type subclassified - subtype 1 : cortical perforation - subtype 2 : nondisplaced crack - subtype 3 : displaced unstable fracture
The Vancouver classification for intraoperative fractures
takes into account
–Site of the fracture
–Stability of the implant –Surrounding bone stock
The Vancouver classification for postoperative fractures
relies upon one or more techniques:
I. direct observation II. clinical suspicion III. radiographic evaluation (full-
length)
cross-sectional imaging has not been routinely used
Diagnosis
Prevention of fractures is preferable even to the most successful treatment options.
Preventive measures during the initial arthroplasty include
- avoiding the creation of cracks, defects or windows in the bone
*if these stress-risers are present bypassing them with a stem that end two to three cortical diameters distal to the defect.
Prevention
preoperative planning to asses risk factors
- detailed history - preoperative radiographs - formulating operative plan
** Adequate soft-tissue releases, hip dislocation, cement removal, canal preparation, and component insertion.**
Regular radiographic follow-up of all patients to detect major osteolytic defects & loosening of the implant
- AP, LA, & Obliq at 1, 2, 5, 7, & 10 Mos then every 2-3 yrs.
objectives: - to promote early healing - to preserve or
reconstitute the bone - to restore the correct
alignment and length - to achieve a stable
fixation of the prosthesis - Restore mobility and
function
Management
1. Conservative
2. Surgery
Management
Highest
High Failure RateHigh Failure Rate
*Only for simple & Stable # and medically unfit *Only for simple & Stable # and medically unfit
Fracture configuration Implant stability Bone stock
Surgery
Reconstruction
Impaction grafting Impaction grafting . Proximal femoral . Proximal femoral
replacementreplacement
Revision THRORIF
Cerclage Plate Strut grafts combination
Long stems Cemented Uncemented
Impaction grafting Proximal femoral
replacement
Current indications
Prophylactically • Increase hoop stress resistance (Incavo 1991)
Temporary (Jando 2007)
• until further intramedullary or extramedullary fixation
Definitive (Jando 2007)
• Simple periprosthetic # - alone Trochanteric # Spiral #
• Complex periprosthetic # - with other devices Plates or strut graft
ORIF with Cables
•
ORIF with Plates
Advantages No transcortical fixation High union rate when
used with intramedullary device (De Ridder 2001))
Disadvantages Can’t used alone
Partridge nylon plates and straps
Proximal cables, distal screws satisfactory result in over 80% of cases
(Zenni 1988))
Ogden plates
Advantages Minimal skill set Stronger than strut
graft Early mobilization High union rate when
used with cortical struts (Wang 2000)
Disadvantages Requires dissection to
plate length
Compression plates
Advantages Minimal dissection Preserves blood supply Rigid internal fixation
Disadvantages More expensive than
dynamic plate Requires special
training More fluoroscopic
exposure
LISS plates
‘internal external fixator’ Two anatomical models
• diaphyseal plates• distal femoral plates
no advantage to the locking screw system (Buttaro 2007 & Zdero 2008)
encouraging results for B1 & C (Berlusconi 2004, Chakravarthy 2007, Bryant 2009, & Ehlinger 2010a)
extra-periosteal application --------- periosteal blood supply
Locking plates
good option in the elderly (Baker 2004 )
Carbon fibre plates
Advantages No transcortical
fixation
Disadvantages Requires extensive
dissection Prone to fracture or
bend
Mennen plates
Advantages Allow adequate
attachment of cables, wires & screws
Early mobilization High union rate when
used with cortical struts
Disadvantages High failure rate when
used alone
Dall-Miles plates
Advantages High union rate Easily contoured Low elastic modulus
Disadvantages May weaken after
implantation Expensive Graft/host interaction Not as strong as plates
Cortical strut allograft
Consider when the Implant• Loose• Implant #
Revision hip arthroplasty
prosthesis must bridge the fracture by at least two shaft diameters (Duncan 1995)
options are cemented stems cementless stems
• proximally coated• extensively coated• modular
revision stems that are cemented, or rely on proximal fixation
revision in total hip arthroplasty is often complicated by insufficient proximal bone stock
remaining bone is inadequate to provide structural support, osteogenic potential for bone ingrowth, or a surface that allows for cement interdigitation.
cemented stems
Indications:•older + simple fracture pattern that
can be reduced anatomically •osteoporotic bones where a change to
a cementless fixation would be more difficult
increasingly popular because they provide the potential for long term biologic implant fixation
biological ingrowth around the porous coating provides the potential for long-term prosthetic stability
Cementless stems
proximally porous-coated stem • disappointing (Mulliken 1996)
extensively porous-coated stem• superior fixation (Springer 2003)
Hydroxyapatite-coated stem • enhance early fixation (Karrholm 1994)
proximal femoral replacement • last option
Indication:• elderly with limited life expectancy where
severe bone loss precludes a simpler reconstruction
TREATMENT STRATEGIES
Claw plate
Claw plate
Confirm implant stability intraoperatively
Type C fractures •Ignore implant & treat fracture
gold standard treatment of this # is surgery with an exception of selected simple # .
Evaluate Stability of the Implant & bone quality If the implant is stable and bone quality is adequate
for fixation…..the implant should be retained while the # is fixed following standard principles or conservative
If the implant is loose or bone quality is poor ….the implant should be revised while fixing the fracture
When there is massive bone loss, proximal femoral replacement with allograft or with a massive structural prosthesis is used
Conclusions