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The management of complex periprosthetic fractures

Open AccessPublished:October 18, 2016DOI:https://doi.org/10.1016/j.artd.2016.09.011

      Keywords

      Total hip and knee arthroplasties have been 2 extremely successful surgeries with respect to providing pain relief and increasing mobility. The number of primary and revision total hip arthroplasties continues to increase, and with this, the incidence of periprosthetic fractures continues to rise. Periprosthetic fractures around total hip and knee arthroplasties can prove to be a particularly challenging problem depending on location, bone quality, current implants, and patient comorbidities. Due to this, we advocate that only experienced surgeons address and treat complex periprosthetic fractures.
      Several general considerations must be considered when addressing these fractures. Preoperative planning is essential and begins with correctly classifying the fracture pattern that is present. Correctly classifying the fracture allows for detailed treatment plans to be formulated. Asking the patient if he or she had pain before the fracture is crucial. This may signify that the implant was loose prior to the fracture and change the treatment algorithm. A stable prosthesis-cement-bone or prosthesis-bone interface is essential for the function and survival of the components. Templating is extremely valuable and allows for the treating surgeon to ensure that the correct hardware and prosthesis are present for the case. Finally, it is important to follow Arbeitsgemeinschaft für Osteosynthesefragen fracture principles to create a stable construct with preservation of native biology.
      The articles in the December issue of Arthroplasty Today illustrate the wide variety of complex periprosthetic fractures that may arise in a busy adult reconstruction practice. The authors have clearly demonstrated unique techniques to address specific periprosthetic fractures.
      Martin et al. describe a unique subset of patients—bilateral pelvic discontinuities. Unilateral discontinuities have been a difficult entity to treat, and this subset of patients, further increases the difficulty level. As we have previously discussed in the literature, pelvic discontinuities should only be treated by the most advanced adult reconstruction surgeons. When treating a chronic discontinuity, 3 different treatment techniques can be used: cup cage, triflange, and distraction. The commonality among the 3 methods is that internal fixation should not be used to treat chronic discontinuities, and therefore, plating should be avoided.
      In the manuscript by Tetreault and McGrory, the authors attempt to address treatment of greater trochanteric periprosthetic fractures. There have been numerous treatment options described in the literature, but each is associated with potential complications. The authors describe a technique that has been successful in addressing fractures in other areas of the body and have identified a treatment option that should be kept in the armamentarium of revision surgeons. We believe that careful selection and assessment of the greater trochanteric fracture must be considered in light of the complications that have been associated with greater trochanteric open reduction and internal fixation. It should be noted that many fractures of this type treated nonoperatively do better than expected without the potential surgical complications.
      The first 3 case reports demonstrate the creative nature of experienced surgeons addressing these complex fractures. Hedlundh and Karlsson present a novel technique to treat a complicated Vancouver B1 fracture. Once again, it is vital to be absolutely sure of the fracture classification specifically when dealing with B1 vs B2 fractures. Familiarity and experience with a prosthesis system allow for these challenging fractures to be addressed and treated. As discussed by Sandilands et al., atypical femur fractures with associated severe hip arthritis are a difficult problem. We agree that these fractures are best treated with only one surgery and advocate the use of cementless fixation to treat this problem. Jethanandani et al. likewise illustrate the complexity of this type of fracture.
      The articles highlighted in this series demonstrate the complex nature of periprosthetic fractures as well as atypical femur fractures and the need for only experienced surgeons to address these problems. Even in the most experienced hands, these fractures are extremely challenging to tackle. Both detailed preoperative planning and careful intraoperative decision-making are vital to the successful treatment of these fractures.

      Appendix A. Supplementary data