Presenter: THA femoral periprosthetic fractures difficult, but not impossible to manage
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When faced with the sometimes-challenging biomechanics, deforming forces and bone quality of patients with periprosthetic fractures in total hip arthroplasty, surgeons should use over-contoured plates and dual plates that span the femur.
Additionally, Elizabeth B. Gausden, MD, MPH, said at the Current Concepts in Joint Replacement Meeting, for proximal fixation, surgeons should not rely on cables during open reduction and internal fixation (ORIF),
“Use cables reluctantly. I think it’s something we’re all comfortable with, but biomechanically, they’re not going to be as strong as a screw. You may need them, but that shouldn’t be your first choice,” Gausden said during a presentation in which she discussed key concepts, overall principals and surgical techniques that may help keep patients from a return trip to the OR when they present with a periprosthetic femur fracture and a well-fixed THA stem.
A series of THA periprosthetic femur fractures treated during a 10-year period that Gausden and colleagues studied showed the seriousness of this diagnosis. After initial treatment, one of three patients in the study with B1 femur fractures returned to the OR within 2 years “and one of five is going on to nonunion, so this is a real problem,” Gausden said. “These are hard fractures to deal with and I think, as soon as you get one of these, you have to treat it with respect in that way. These are challenging biomechanics.”
In addressing periprosthetic fractures, varus forces that deform the femur must be overcome and these call for expedient treatment, according to Gausden.
“You have to think of these as the race between union and implant failure. If you leave the OR with any degree of varus, it’s not going to be tolerated. Just go ahead and fix it right away because it will not heal, and the way I like to do this [is by] over-contouring the plates into valgus,” she said.
Among other suggestions for successful ORIF of type B periprosthetic femur fractures Gausden gave were using a radiolucent table, positioning the patient laterally and obtaining a radiograph so that every feature of the fracture is visible preoperatively.
“[I use a] subvastus approach, and preserving the periosteum is totally key. These need as much biology as they can to heal,” she said. Use of traction and clamps is permissible, Gausden said. “You can be more creative than you think around a stem.”
References:
Gausden EB, et al. J Arthroplasty. 2021;doi:10.1016/j.arth.2021.02.048.
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Gausden EB. Periprosthetic fracture THA suitable for ORIF: Decisions; technical tips. Presented at: Current Concepts in Joint Replacement Meeting; Dec. 7-10, 2022; Orlando (hybrid meeting).
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