Periprosthetic fracture

periprosthetic fracture

1. Periprosthetic Fracture Dr. Jatinder S. Luthra (MS , DNB, MRCS)

2. Projected Primary and Revision TKR 673 % Increase in Primary TKA Kurtz et al JBJS 2007 601% Increase in Revision

3. Oman perspective

4. Incidence Mayo Clinic – Largest series ( 19810 primary tkr ) Femur – 2% Patella – 0.5% - 1.0 % Tibia - 0.4% Average - 0.3% – 3.0 % Incidence 1.2% Incidence Revision surgery – 38%

5. Incidence With in 15 cm from joint line Stemmed implant - < 5cm from the tip of stem Low energy falls – 90 %

6. Risk Factors Increasing age Female Osteoporosis Revision arthroplasty Rheumatoid Arthritis Ch. Steroid therapy Arthrofibrosis Neurological diseases

7. Risk Factors Ant. Femoral Notching Biomechanical & Finite element analysis – 3 mm notching Bending & Torsional strength by 1/3 Many Clinical studies – do not prove ? Bone remodelling Debatable Notching 28% 2 periprosthetic fracture

8. Classification Type Rorabeck I Fracture undisplaced Implant stable II Fracture displaced , Implant stable III Implant Loose Frature Un/displaced

9. Classification Type Su I Fracture proximal to prosthesis II Fracture starts at prosthesis & extend proximally III Fracture distal to flange of prosthesis

10. Classification Type Felix - Classification I Fracture of tibial plateau involving implant bone interface II Fractuer of meta / diaphyseal transition III Fracture distal to tibial component IV Fracture of tibial tuberosity Subtype A Stable implant B Loose implant C Intraoperative fracture

11. Classification Type Goldberg Classification I Fracture not involving implant bone interface or ext mech. II Fracture involving Implant bone interface or extensor mech. III A - Fracture inf pole of patella with patellar lig rupture B – Fracture inf pole patella without patellar lig rupture IV All Types of fracture Dislocations

12. Diagnosis History Examination X- rays Ct scan -Mech. of Injury -Pain before injury -Soft Tissue envelope -Extensor mech. - Ap -Lateral -Oblique -Sunrise -Surgical planning -Component stability

13. Management Stable joint without significant malalignment Uneventful and complete fracture healing in 6 months Range of motion & Knee function prior to trauma

14. Management Nonsurgical – Brace / cast Undisplaced fracture with stable implant Stiffness Malalignment Nonunion Pain AmbulatoryStatus

15. Management Surgical options – Conventional Plate & Screw Indication Technique Advantages Disadvantages -Displaced -Minimally Comminuted -Good Bone Stock -Lateral Approach -Minimal periosteal stripping -3 screws in distal fragment 3 screws in proximal fragment Augment with bone graft / cement Anatomic reconstruction Rigid fixation Early ROM Osteopenic Bones Do Not work High incidence Non union Malunion Mechanical failure

16. Management Surgical options - Locking Plate Mainstay of managing these fractures Indication Technique Advantages Disadvantages Lateral approach Anterior approach Polyaxial locking screws Internal fixator Bicortical fixation Pull out from osteoporotic bone Fracture reduced independent of plate – mal-aligned Osteoporotic bones Biomechanically Superior Better Distal Fixation Far Cortical Fixation Reduced Construct stiffness Retain strength Symmetric callus Bottlang et JBJS 2010

17. Management Surgical options - Supracondylar IM nail Indication Technique Advantages Disadvantages -Displaced -Markedly Comminuted -Open Box implants Med. Parapatellar app. Open with awl Minimal stripping Fracture haematoma undisturbed Load Sharing Device Reaming stimulate healing Closed Box implants C/f – very distal fracture

18. Evidence Surgical options - Locking Plate Better ROM VS IM nail Johnson et al Knee 2011 Lower Malunion rate Ristevski JOT 2011 Lower Nonunion rate Althausen etal JOA 2003 Extreme distal Fracture Streubal et al JBJS 2010

19. Evidence Surgical options - Locking Plate Inconsistent and asymmetric Callus Formation Lujan et al JOT 2010 Nonunion rates – 28 % Henderson et al CORR 2011 Boulton et al 2011 Gross etal 2011

20. Evidence Compare locking plate & Nail Case reports/Series No Trials Large et al Locking plate better – ROM No non union No Difference

21. Management Surgical options – Revision Arthroplasty Hinged Knee prosthesis - Majority Distal Femoral Replacement Indication Severely comminuted fracture Poor Bone stock Very distal fracture Loose prosthesis Bone grafting - Debatable

22. Management - Algorithm Periprosthetic Femur fracture Open Box Design Closed Box Design Stable Implant Loose Implant Stable Implant Loose Implant Type I - II Type III Type I - III Type I - II Type III Type I - III ORIF/CRIF Locked plate / Retrograde nail ORIF/CRIF Locked plate / Revision Revision Arthroplasty Revision Arthroplasty ORIF/CRIF Locked Plate ORIF/CRIF Locked plate / Revision

23. Management - Algorithm Periprosthetic Patellar Fracture Type I Type II Type III Exten Mech. Exten Mech Intact Implant loose Intact Conservative Component Remove & reimplant after bone healing Exten Mech Rupture Implant stable ORIF A B Loose Stable Loose Stable Explant & recon Recon/ SOS ORIF Explant Conservative

24. Management - Algorithm Periprosthetic Tibial fracture Type I Type II Type III A B B A A B Conservative Change Component ORIF/CRIF Lock Plate Change Component + ORIF

25. Outcome Infection 3% Implant failure 4% Malunion 9% Revision Surgery 14%

26. Intraoperative fractures Femur – Diaphyseal fracture -stemmed implant Discovered post op – post pone weight bearing 6-8 weeks till healing Femur – metaphyseal fracture – undisplaced conservative Displaced – intramedullary stem with transcondylar screw

27. Ipsilateral hip and knee Avoid stress riser Overlapping of femoral stem with tibial plate Supplementary cables / strut graft Locking attachment plate

28. Interprosthesis Distance < 10 cm – overlap the two prosthesis > 10 cm - ignore

29. Nailed Cementoplasty Bobak et al JOA – 2010 5 patients – Advanced osteoporosis ASA grade 3

30. Nail plate fixation

31. Miot Hospital Chennai

32. Femur Type 3 – Revision Arthroplasty

33. Femur – Type 2 – Locking Plate

34. Femur Type 3 – Locking plate

35. Felix Type 3 – Locked Plate

36. Summary Anterior fem. Notching – Femoral stem extension Avoid eccentric box cut Use stem to augment – wedges / graft Bypass the stress risers with stems – 2 canal diameters Revision surgery -prosthesis removal in gentle stepwise manner Tibial component removal – oscillating saw Severe osteopenia / unsteady gait – use a cane/walker