Assessment and management of peri-prosthetic fractures
by James Donaldson

Hip peri-prosthetic fracture

History
Age – elderly, often low energy. Increasing in incidence
Original surgery – when, indication, surgeon, complications (infection)
Early – within 6 months of surgery. Often uncemented components
Late – beyond 6 months of surgery
Past medical/surgical history
Medication/drugs and allergies
Radiographs / Imaging:

• AP pelvis, AP and lateral of involved hip
• AP and lateral of whole femur

AP x-ray hip showing peri-prosthetic fracture and post-op following revision stem with fixation of the fracture

Signs & Symptoms
Pain, swelling, rotational deformity of leg
Unable to weight bear

Risk factors
Elderly
Osteoporosis
Poor bone stock
Revision surgeries
Uncemented femoral prosthesis

Initial treatment
Similar to neck of femur fracture
Analgesia, O2, IV fluids
Skin traction for comfort
Admit for surgery

Classification (Vancouver)
A – fracture in trochanteric region
B – fracture around the stem
B1 – good bone and well fixed stem
B2 – loose stem but good bone
B3 – loose stem and poor bone stock
C – fracture distal to the tip of the stem

Definitive management
Nearly all need operative fixation (unless medically moribund or completely undisplaced type A)
Fixation with wires, cables and plates
Revision prosthesis in B2 and B3 types
Proximal femoral replacement is another option in the elderly and less mobile where immediate mobility is preferred

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Knee peri-prosthetic fractures

History
Age – elderly, low energy injuries
Similar to peri-prosthetic hip fractures   

Radiographs:

• AP and lateral knee
• Consider AP and lateral views of the tibia or femur depending on  the extent of the fracture and what bone is involved

AP and lateral x-rays demonstrating peri-prosthetic fracture femur above total knee replacement

Symptoms and Signs
Pain, swelling, bruising, deformity
Inability to weight bear

Supracondylar femur fracture

Risk factors include
Osteoporosis
Rheumatoid arthritis,
Steroids
Notching of the femur (sawing into the anterior cortex during the initial procedure)
Osteolysis

Initial treatment
Analgesia, O2, IV fluids
Skin traction for comfort
Admit for surgery

Definitive management
Operative treatment is usual

• Fixation with a plate or a retrograde femoral nail (need to know the prosthesis design prior to nailing)
• A distal femoral replacement can also be used in the more elderly and less mobile

Tibial fracture
Less common than femoral fractures

Risk factors include

• Long stem
• Loose tibial component
• Osteolysis
• Malalignment
• Revision surgery
• Tibial tubercle osteotomy
  
  

If undisplaced and stable prosthesis, or not fit for surgery, can cast or brace

Surgical fixation is with a long stem revision tibial component or ORIF if the component is stable

Patella fracture
Manage as per patella fracture section (generally requires fixation unless undisplaced)