Chapter 24

PERI-PR O ST H ETIC
F RA CTU RES
Dhiya Luthfiyyah Utami
712021068
Dosen Pembimbing: dr. Rizal Daulay, Sp. OT, MARS.
 Introduction

Periprosthetic fractures are fractures related to or involving

implanted prostheses. In practice, we are talking of fractures
related to hip, knee, ankle, shoulder and elbow prosthetic
replacements. In clinical practice, post- implantation, most of
these fractures are seen in the weight-bearing lower limb
joints, especially around total hip and total knee replacements
and this discussion has been limited to these two joints.
 PERI-PROSTHETIC HIP FRACTURES
Periprosthetic fractures can generally be classified into:
• Intra-operative - those occurring during the initial implantation of the
prosthesis and
• Post-operative - those occurring later.

Risk Factors
RISK FACTORS FOR INTRA-OPERATIVE
FRACTURES DURING THR INCLUDE:
• Patient-related factors: poor-quality bone
due to osteoporosis, previous healed
infection or fracture; previous pathology
such as CDH, poliomyelitis or sickle- cell
disease.
• Surgeon related factors: Poor choice of
patient for THR, poor understanding of the
predisposing pathology, poor exposure and
poor operative technique.
 Classification

JOHANSSON CLASSIFICATION
Type I: Fracture proximal to the tip
of the prosthesis with the stem still
in contact with the medullary
cavity
Type II: Fracture extending distal
to the tip of the prosthesis with
dislodgement of the stem from the
medullary cavity of the distal
fragment
Type III: Fracture distal to the tip
of the stem of the prosthesis

The American Academy of Orthopaedic
Surgeons classification
This classification divides the femur
into three regions/levels:
Level I: proximal femur, distal to
the lower extent of the lesser
trochanter
Level II: 10cm of the femur distal
to Level I
Level III: the rest of the femur
distal to Level II
Fracture Types
Type I: Fracture proximal to the
intertrochanteric line.
Type II: Vertical or spiral fracture not
extending past the lower extent of the
lesser trochanter
Type III: Vertical or spiral fracture that
extends past the lower extent of the lesser
trochanter but not beyond Level II (usually
at the junction of the middle and distal
thirds of the femoral stem
Type IV: Fractures within the area of the
femoral stem, with Type IVA being spiral
around the tip and Type IVB being a simple
transverse or short oblique fracture
Type V: Severely comminuted fractures
around the stem in Level III.
Type VI: Fractures distal to the tip of the
femoral stem
 Management

An “acute” intra-operative fracture should

be recognized as it occurs and fixed there
The Vancouver classification and then.
The Vancouver classification
An unstable fracture occurring sometime
Type A: Fracture in the
after the initial implantation may be treated
trochanteric region (AG stands for
non-operatively or operatively, depending
greater trochanter; AL for lesser
on its features.
trochanter
Immobilization is an important element in
Type B: Fracture around or just
management.
distal to the stem
B1 Stable prosthesis
B2 Unstable prosthesis
B3 Unstable prosthesis plus inadequate
bone stock
Type C: Fracture well below tip of
stem
PERI-PROSTHETIC ACETABULAR FRACTURES
Compared to peri-prosthetic femoral fractures, peri-prosthetic acetabular fractures are rare and the
literature on the subject is correspondingly sparse. A
classification divides them into two types:
Type 1: the acetabular component is clinically and radiologically stable
Type 2: the acetabular component is unstable

PERI-PROSTHETIC SUPRACONDYLAR
NEER CLASSIFICATION (MODIFIED BY MERKEL)
FEMORAL FRACTURES

Risk factors include Type I: Minimally displaced

osteoporosis, stiff knee post- supracondylar fracture
Type II: Displaced supracondylar
TKR, notching of the anterior
fracture
femoral cortex during the Type III: Comminuted supracondylar
operation and pre-existing fracture
neurogenic disease. Notching Type IV: Fracture at the tip of the
prosthetic stem or fracture of the
of the femur is preventable by
femoral shaft above the prosthesis
careful operative technique. Type V: Any fracture of the tibia

Lewis and Rorabeck classification
Lewis and Rorabeck classification
Type I: The fracture is
undisplaced and the bone-
prosthesis interphase is intact
Type II: The fracture is
displaced but the interphase
remains intact
Type III: There is a displaced
or undisplaced fracture and
the prosthesis is loose
Management
Critical issues in management include
anatomic and mechanical alignments as well
as adequacy or otherwise of available bone
stock. Acceptable alignment guidelines
include:
Angulation not more than 5 – 10 degrees
in either plane • Displacement less than 5 –
10 mm
Rotation less than 10 degrees
Shortening less than 1 cm
There are non-operative and operative
options.

Non-Operative Treatment
Cast immobilization
Lewis and Rorabeck classification A long leg cast or cast
bracing can be applied for 4 –
8 weeks for minimally
displaced fractures
Operative Treatment
-ORIF
ORIF using a blade plate, a condylar
buttress plate, dynamic condylar screw,
dynamic compression plate, a locked plate
or a retrograde IMN may be used to
achieve stabilization.
-Primary revision TKR: a stemmed prosthesis is
used if there is bone-implant interphase
involvement and the prosthesis is loose.
-Bone grafting:autologous bone graft, cortical
strut graft and distal femoral replacement with
patient-specific prosthesis may be indicated.
 PERI-PROSTHETIC TIBIAL FRACTURES
CLASSIFICATION BY FELIX ET AL:
Type I: Fracture involving the tibial plateau
Type II: Fracture involving the tibial component stem
Type III: Fracture distal to the prosthesis
Type IV: Fracture involving the tibial tubercle
The stability of the prosthesis is then used to classify the fractures
further as follows:
Subtype A: prosthesis is well fixed
Subtypte B: prosthesis is loose
Subtype C: fracture is intra-operative

MANAGEMENT

Non-operative
Reduction by MUA followed by cast immobilization for 3-4 weeks, then cast-
bracing to facilitate movement: suitable for tibial shaft fractures (Type III)
Operative
• Type I fractures: ORIF or revision of the tibial component plus or minus bone
grafting, depending on the severity of the fracture and the stability of the prosthesis
• Types II, III and IV: ORIF if non-operative options are unsuccessful
 PERI-PROSTHETIC PATELLAR FRACTURES

Patellar resurfacing as part of TKR is not accepted by all knee joint replacement surgeons. It is
difficult to accurately put a figure to those who resurface the patella and those who do not.
Peri-prosthetic fractures generally have a low incidence - 0.3-5.4 %.

GOLDBERG’S CLASSIFICATION
PRE-DISPOSING FACTORS INCLUDE:
Type I: Fractures not involving cement/implant
Excessive resection of the patella
interphase or quadriceps mechanism
Component with a large central peg
Type II: Fractures involving cement/implant
Thermal necrosis of the patella from interphase and/or quadriceps mechanism
bone cement Type IIIA: Fractures of the inferior pole with
Patella malalignment patellar ligament disruption
Excessive flexion of the femoral Type IIIB: Fractures of the inferior pole without
component patellar ligament disruption
Type IV: Fracture-dislocations
 TREATMENT
NON-OPERATIVE
Types I or IIIB i.e. there is no component loosening, implant
malalignment or extensor mechanism rupture: Cast immobilization
or castbrace - for 4-6 weeks, partial weight-bearing on crutches.

OPERATIVE
Operative treatment is indicated if there is extensor mechanism
disruption, patellar dislocation or prosthetic loosening:
• ORIF with revision of the patellar button: Types II, IIIA and IV
fractures
• Fragment excision – for small fragment which will not
compromise stability or tracking
• Patellectomy - for very comminuted or devascularized patellae
THANK
YOU!