PERIPROSTHETIC FRACTURE
A 68-year-old woman is brought to the emergency department after falling in the shower. Her radiograph is above.
- Describe the appearances in this radiograph.
This is an AP radiograph of the left hip and femur. It shows a cemented total hip replacement that looks well-fixed and an associated periprosthetic fracture of the femur at the level of the tip of the prosthesis. I would obtain additional radiographs so that I have adequate AP and lateral imaging for the hip and the whole femur, and I would classify this using the Vancouver system of classification proposed by Duncan and Masri, although I know that Duncan has proposed an update to this classification system, the unified classification system.
Based on the imaging available, I believe that this is a type B-1 fracture.
- How would you manage and investigate this patient?
I would undertake a full history and examination of this patient. These injuries are more common in frail elderly patients and I would pay particular attention to the
cause of the fall, co-morbidities, pre-injury function and satisfaction with the hip replacement and also any suggestion of wound problems or infection following the original surgery. I would send routine blood samples for full blood count, serum electrolytes and a sample for group and save. I believe this fracture would be best treated operatively. I would also send samples for CRP and ESR as part of a general screen for infection. I would prepare the patient for theatre, obtaining an electro- cardiogram and chest x-ray if necessary based on the history and clinical findings. I would also ensure that this patient is assessed for her risk of fragility fractures with a falls assessment and dual energy x-ray absorptiometry (DEXA) scan. In my unit this is part of a detailed assessment from the orthogeriatric service.
- What are the treatment options for this patient?
This can be treated with operative or non-operative management. Non-operative management with traction is possible as the implant is well-fixed as long as align- ment is maintained, but this will leave the patient exposed to all the risks of pro- longed recumbency.
I would advise operative management. I would choose to use an open sub-vastus approach to reduce the fracture and to temporarily stabilise it with cerclage wires. This would also allow me to take perioperative tissue samples for microbiology. I would choose to apply a locking plate (LC-DCP) to the lateral aspect of the femur using several unicortical screws proximally so as not violate the cement mantle of the femoral stem and using bicortical screws more distally. I would reposition or completely replace the temporising cerclage wires so that two or three wires provide additional stability to the proximal construct where the screw fixation is unicortical. In addition, if there is an obvious cortical defect or marked comminution I would use a femoral cortical strut allograft which I would lay on the anterior aspect of the femur so that it bypasses the defect or area of comminution by at least two cortical widths. I would incorporate this into the cerclage wire fixation.
The evidence for the use of locking plates, cerclage wires or onlay cortical strut grafts is limited to case series. There is, however, some good evidence that where the fracture pattern is a B-2 type, with a loose femoral implant, the results of arthro- plasty are superior to those of operative fixation.