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Periprosthetic Fractures following THR

Incidence:

  • 1% after primary THA

  • 4% after revision THA

Prevention: 

  • better than the most succesful treatment option

  • avoid Cortical defects

  • avoid malalignment of prosthesis

  • regular radiological follow-up

RISK FACTORS: 

  1. inadequate calcar cancellous bone removal (with subsequent calcar resorption)

  2. varus positioning of the stem

  3. lateral stem nicks produced by drilling for greater trochanteric wires

  4. progressive osteolysis

MANAGEMENT 

Management Aims:

  • Restore function

  • United fracture

  • Stable prosthesis

  • Preserve bone stock

Management depends on:

  • Location of fracture

  • Stability of prosthesis & fracture

  • Quality of bone stock

Johansson et al. classified these fractures into three types:

  • Type 1 fractures - occur proximal to the tip of the prosthesis with no distal extension

  • Type 2 fractures - extend from the proximal portion of the shaft to a point beyond the distal tip of the prosthesis

  • Type 3 fractures- occur entirely distal to the tip of the prosthesis. 

Johannson et al. reported unsatisfactory results in nearly two thirds of patients. Therefore these fractures are better prevented than treated. Avoidance of cortical perforations, appropriate intraoperative management of bony deficits, proper prosthetic selection, and restricted weight-bearing when appropriate will minimize the occurrence of this difficult problem.

In general, if the prosthesis is well fixed and if the fracture is minimally displaced, a trial of non operative treatment is indicated

Femoral shaft perforations: 

  • need to bypass perforation by at least one and one half shaft diameters in order to reduce risk of shaft fracture through the perforation

  • clinical recommendations have been to use a femoral component that ends 2-3 shaft diameters distal to the perforation

Proximal femur fracture; 

  • fracture usually cannot occur unless there is loss of fixation of proximal femoral component

  • fracture may have produced disruption of the bone cement prosthesis interface or there may have been preexisting loosening

  • requires revision of the femoral component



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