Use calculated treatment algorithms for ideal care of periprosthetic fractures after TJA
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Key takeaways:
- Complex generalists are the best-equipped physicians to perform periprosthetic fracture revisions, according to a presenter.
- The presenter said the number one consideration in fracture care is patient history.
KOLOA, Hawaii — Surgeons must devise and implement calculated treatment algorithms when performing periprosthetic fracture revisions following total hip and total knee arthroplasties, according to a presenter here.
In his presentation at Orthopedics Today Hawaii, Frank A. Liporace, MD, chair of the department of orthopedics at Cooperman Barnabas Medical Center, said the revision setting for periprosthetic fractures following THA and TKA requires multifaceted surgeons skilled in multiple areas.
“Sole trauma guys are not the right person for this in many cases. Sole joints people are not the right person for this in many cases,” Liporace said. “The complex generalist is probably the best person for a lot of these cases.”
According to Liporace, the number one consideration when operating on a periprosthetic fracture is a patient’s history.
“You have to ask the person, not just look at their CT and their X-ray, how was this joint functioning,” Liporace said. “Because if the joint was functioning [poorly], that could be mechanical or subtle septic instability causes that are going on. And you could totally miss the boat by treating the X-ray and the CT scan.”
Hip
For periprosthetic fracture of the hip following THA, Liporace said “it is important not to have blinders on,” when performing intraoperative testing. He said patients can have both mechanical and bacteriological problems that need to be addressed.
In addition, Liporace said it is imperative to distinguish between type B1 and type B2 diaphyseal fractures to determine whether an unstable or loose stem with good surrounding bone stock quality is fixable.
He added that hip spline stems that are tapered may be helpful in fracture fixation.
“When you are considering these revisions, hip spline stems that are tapered, whether monoblock or not, are helpful because you do not need that 6 to 9 centimeters that we used in cylindrical diaphyseal stems in the past,” Liporace said. “You can go way down into the metaphysis, and you could use it in combination with plates as a nail-plate combo.”
Knee
For periprosthetic fractures in the knee following TKA, Liporace said there are several factors that will determine whether a distal femoral replacement is necessary.
“We have to come up with an algorithm that makes sense,” Liporace said. “When we look at the metaphyseal zone, if the epicondylar area is split off and it is creating an instability and it goes medial to the anterior flange deep within the implant or in the intercondylar area, those should get a [distal femoral replacement] DFR.”
After deciding resection level, he said it is important for surgeons to cut proximal to the gastrocnemius and to cut 5 millimeters less than surgeons think they need to not create a patella infera.
“When should we consider a dual implant fixation? [When there is] obesity, long segment comminution and severe osteoporosis,” Liporace said. “It is important you do not have an intercondylar split zone in the implant.”
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Liporace FA. Periprosthetic TKA & THA fractures: 5 tips in 5 minutes. Presented at: Orthopedics Today Hawaii; Jan. 12-16, 2025; Koloa, Hawaii.
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