11/19/2018 InterprostheticFractures: Challenges, Options ...

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Frank Liporace, MDChairman & VP, Dept of Orthopaedics

Chief of Trauma & Adult Reconstruction Jersey City Medical Center / RWJ Barnabas Health

Interprosthetic Fractures:Challenges, Options, Techniques

Reasons Susceptible

• Rate of Arthroplasties

• Lifetime Risks - 7% chance peri-implant failure all comers

• Intramedullary stems (Lehman W, et al 2011; Rupprecht M, et al 2012)

– Decreased strength over time of femur

• Osteoporosis

Considerations• Implants above and

below– TJR + stems

– Fracture implants• Healing of prior

injury?

• Implant stability

• Bone Quality

• Location of injury

• Infection?

• Available Bony Real estate

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Decision Matrix

MF

Issues:- IT healed- Lag screw track- Distal real estate

MF

Ca PO4 screw tract augmentation+

Span entire femur with long plateCaPO4 vs PMMACollinge et al JOT 2007

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MF

Need ANATOMIC reduction!SINGLE Fracture line!100% Strain at fracture

NH

NH

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NH

Use your surroundings:- Cement mantle- Implant - Stay anterior - lateral

NH

-Get at least 2 cortical diameter overlap-Have some form of proximal screw fixation

Brooks et al 1987Bryant et al 2009

NH

COMMINUTION Bridge Plate, Percutaneous Application !!!

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97 yo retired nurse 3 wks s/p HHA for FNF

•Fracture

•TKR below

•Stem Loose?

•Infection?• Time since procedure?

FAL

Options:

-Cables + Plate / Allograft

-Cables + Revision Stem

FAL

Other Considerations:

-Fall Risk

-Osteoporosis

• WB’ing status post-op?

FAL

• Augmented & Prophylactic plating

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GP-92 year old: Failed FNF screws 15 yrs earlier

-Intra-op fx THA with “fixation”

-10 years ago supracondylar femur fx

-Pain, can’t ambulate last 8-9 months

ISSUES:-Stem protrusion

-Femoral perforation

-DeformityFAL

GP

-Mega Prosthesis-Prophylactic Plating

What to do?

Infected?

Nonunion & Implant Failure

SE – 67 yo F; s/p total of 40+ lifetime surgeries - 3 strikes this

hip

FAL

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SE – 3 strikes

Resection Nonunion

Antibiotic Coated Plate

Antibiotic Spacer HHA

FAL

Stage 2

Plate Exchange

Revision THA

SE – 3 strikes

FAL

SE – 3 strikes

FAL

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JV – 57 yo male

3 time failed distal femoral nonunion

ALL surgeries with lateral plate

Previous Hip Fx short IMN above

SOLUTION ???

STEP 1 – BIOPSY (significant history)

NEGATIVE FOR INFECTION

NOTE ALLOGRAFT FIBULA INTRAMEDULLARY STR

B.S. signBone Stimulator

Problems?

• Metaphyseal zone

• Very rigid fixation with large moment arm

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Challenges

• Elderly

• Need immediate weightbearing

• Decreased bone stock– Osteopenia– Multiple surgeries

• Previous implant above

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1 year

LINKED CONSTRUCT

Appropriate Stability

HEALED

NO PAIN !!!

• Fracture

• Stem Loose?

• Infection?• Time since procedure?

62 yo s/p IT Fx w/ HHA, s/p 2nd fall w/ cable, s/p 3rd fall w/ pus!!!

FAL

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Leg length?

FAL

Fall #4 – Now what ???

FAL

JZ

Distal Femoral Fx 10 yrs ago w/ 4 time nonunion s/p platings

above TKR

THR above that had previous fxat stem tip

Non-ambulator x 2.5 years

INFECTED ???

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Negative Nuclear Studies

Negative ESR & CRP

ROUND 1

RESECTION ATROPHIC NU

ANTIBIOTIC PLATE

ROUND 2: Nail - Plate

Current IMN offeringCan promoteAPEX POSTERIOR:

Future Directions Distal angular options?

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2.5 months post-definitive op

Uses walker – 1st time in 2.5 yrs

Proximal and Distal N/P Linkage

CALLUS !!!LINKED Plate / NailBOTH:Proximally &Distally w/ IMN

LISS > IMNDEFORMATION W/CYCLICAL LOADING

ELASTIC

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IMN & LISSSIMILARPERMANENT DEFORMATION

PLASTIC

AXIAL LOADING:LOAD-TO-FAILURE

-IMN < LISSLOW BMD

-IMN > LISSHIGH BMD

WHERE COULD WE GO WITH THIS?

• Plate – Nail combo’s

– INTERPROSTHETIC - Fx “needing” a nail with a THR above or rev TKR below

– OSTEOPOROSIS (Chen SH, et al, Knee 2014)

– METAPHYSEAL NONUNION requiring better fixation

– AVOID DEFORMITY (Distal Femur, Proximal & Distal Tibia)

– “DIAL-IN” STABILITY

Koval KJ, Seligson D, Rosen H, Fee K. J Orthop Trauma. 1995;9(4):285-91. Distal femoral nonunion: treatment with a retrograde inserted locked intramedullary Nail

•25% union rate of nonunions with retrograde IMN alone

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NEUTRAL AXIS

Change location ofNEUTRAL AXIS:INCREASE COMPRESSIVESIDE

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Short Segment Interprosthetic& Involving Cup side

Femur Subsidence & Acetabular Failure

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Femur Subsidence & Acetabular Failure

Femur Subsidence & Acetabular Failure

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71 yo Male, 11/2017

• HPI: – THA 5 yrs ago,

– Revision THA 2 years ago,

– Fixation greater trochanter 6 months ago,

– Fall 2 months ago and told, “cup moved a little, wait it out

G.T. Fx & Acetabular Failure

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G.T. Fx & Acetabular Failure

TKR Below

PLAN: EXPLANT AND ABXSPACER

NOW WHAT ?!?!?!?

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Technique

Use of an "antibiotic plate" for infected periprosthetic fracture in total hip arthroplasty.Liporace FA, Yoon RS, Frank MA, Gaines RJ, Maurer JP, Polishchuk DL, Choung EW.J Orthop Trauma. 2012 Mar;26(3):e18-23

Check the Leg Lengths

2 MONTHS LATER…PLANNING STAGED TREATMENT

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FINAL PROCEDURE

NOW WHAT ?!?!?!?

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MJ

• 82 yo female– 4 yr prior TEA

– “chronic suppressive abx” for 2.5 years

– Fractured 1 year prior in splint

– “multiple joint arm” on presentation

• PMH: HTN, CAD, Schizophrenia

MJ – 85 yo F

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JBJS 2014

JBJS 2014

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JBJS 2014

JBJS 2014

JBJS 2014

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JBJS 2014

JBJS 2014

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~7 weeks

6 months

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Take Home Points• Evaluate bone quality

• Evaluate implant location

• Evaluate remaining bone real estate

• Check for infection

• Be prepared for revision

• Span the entire femur / Tx & Prophylactic

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THANK YOU