Periprosthetic FRACTURES

Periprosthetic
Fractures of the
Hip and Knee
Surgical Techniques and Tips

Frank A. Liporace
Richard S. Yoon
Editors
https://t.me/MBS_MedicalBooksStore
123
Periprosthetic Fractures of the Hip and Knee
Frank A. Liporace • Richard S. Yoon
Editors
Periprosthetic Fractures
of the Hip and Knee
Editors
Frank A. Liporace, MD Richard S. Yoon, MD
Division of Orthopedic Trauma and Adult Division of Orthopedic Trauma and Adult
Reconstruction Reconstruction
Jersey City Medical Center – RWJBarnabas Jersey City Medical Center – RWJBarnabas
Health Health
Jersey City Jersey City
NJ, USA NJ, USA
ISBN 978-3-319-43007-2 ISBN 978-3-319-43008-9 (eBook)

https://doi.org/10.1007/978-3-319-43008-9
Library of Congress Control Number: 2018960890
© Springer Nature Switzerland AG 2019

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Preface
Delving deeper into the twenty-first century, the sheer number of total hip and total
knee arthroplasty being performed continues to increase at an exponential rate.
Contributing to this large increase is a combined effect of patients living longer and
technology improving to allow for younger patients to receive long-lasting joint
replacements. Herein lies the inevitable, concurrent rise in complications, including
periprosthetic fractures.
In this specific arena, however, while advances in technology and research have
provided the ability to successfully treat these difficult injuries, we are still learning
more and more about these complex fractures in an elderly, infirm population.
Achieving desired clinical outcomes not only include reliable bony healing but
early mobilization, avoiding morbidity and mortality, and a return to function that
closely resembles pre-injury status.
The purpose of this book is to reach an audience who wishes to have the tips,
tricks, and tools in treating these difficult fractures and have a ready reference guide
that can immediately aide them in the operating theater. We have leaned on our clos-
est colleagues, who frequently treat periprosthetic fractures, and their thought pro-
cesses and offer this case-based book that tackles common clinical scenarios and
how to apply our preferred methods of operative treatment. Immediate help in the
operating room can translate into improved care for our patients, which, in the end,
is the most important goal to achieve.
Jersey City, NJ, USA Frank A. Liporace, MD

Jersey City, NJ, USA Richard S. Yoon, MD
v
Contents
Part I Before the Surgery

1 General Consideration and Workup of Periprosthetic Fractures �� 3
Matthew A. Frank and Hassan R. Mir
Part II Periprosthetic Fractures About the Hip

2 Management of Periprosthetic Acetabular Fractures�� 21
Aaron J. Johnson and Theodore Manson
3 Periprosthetic Fractures About the Acetabulum:
Management of the Loose Component�� 35
Tori A. Edmiston, P. Maxwell Courtney, and Brett R. Levine
4 Periprosthetic Fractures Around Total Hip Arthroplasty
with a Stable Component�� 53
Peter J. Shekailo, Erik N. Kubiak, Richard S. Yoon,
and Frank A. Liporace
5 Periprosthetic Femur Fractures Around Total Hip
Arthroplasty with a Loose Component�� 73
Joshua Rozell and Derek J. Donegan
Part III Interprosthetic, Interimplant and Periprosthetic

Fractures About the Knee
6 Interprosthetic Fracture Fixation: Achieving Stability and Union�� 99
Donald M. Adams, Robinson Pires, Richard S. Yoon, and Frank A.
Liporace
7 Periprosthetic Fractures Around Total Knee Arthroplasty
with a Stable Femoral Component �� 109
John S. Hwang and Cory Collinge
vii
viii Contents
8 Management of Periprosthetic Fractures Around a Total Knee

Arthroplasty with a Loose Femoral Component�� 133
Michael Suk and Michael R. Rutter
9 Periprosthetic Fractures Around a Total Knee
Arthroplasty with a Stable and Loose Tibial Component�� 143
Jeff R. Petrie, Adam A. Sassoon, and George J. Haidukewych
Index�� 159
Contributors
Donald M. Adams Jr, DO, MS Division of Orthopedic Trauma and Adult
Reconstruction, Jersey City Medical Center – RWJBarnabas Health, Jersey City,
NJ, USA
Cory Collinge, MD Orthopedic Specialty Associates, Ben Hogan Center, Fort
Worth, TN, USA
P. Maxwell Courtney, MD Rothman Institute, Philadelphia, PA, USA
Derek J. Donegan, MD Department of Orthopedic Surgery, Hospital of the
University of Pennsylvania, Philadelphia, PA, USA
Tori A. Edmiston, MD, SA-C Department of Orthopedic Surgery, Rush University
Medical Center, Chicago, IL, USA
Matthew A. Frank, MD Orthopedic Trauma and Reconstruction Service, North
Mississippi Medical Center, Orthopedic Trauma Clinic, Tupelo, MS, USA
George J. Haidukewych, MD Division of Orthopedic Trauma and Complex Adult
Reconstruction, Department of Orthopedic Surgery, Orlando Regional Medical
Center, Orlando, FL, USA
John S. Hwang, MD Department of Orthopedics, Carolinas Medical Center,
Charlotte, NC, USA
Aaron J. Johnson, MD, MS Department of Orthopedics, University of Maryland
School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
Erik N. Kubiak, MD Division of Orthopedic Trauma and Adult Reconstruction,
Department of Orthopedic Surgery, University of Nevada – Las Vegas, Las Vegas,
NV, USA
Brett R. Levine, MD, MS Department of Orthopedic Surgery, Rush University
Medical Center, Chicago, IL, USA
ix
x Contributors
Frank A. Liporace, MD Division of Orthopedic Trauma and Adult Reconstruction,

Jersey City Medical Center – RWJBarnabas Health, Jersey City, NJ, USA
Theodore Manson, MD, MS Department of Orthopedics, University of Maryland
School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
Hassan R. Mir, MD, MBA, FACS University of South Florida, Tampa, FL, USA
Florida Orthopedic Institute, Tampa, FL, USA
Jeff R. Petrie, MD Division of Orthopedic Trauma and Complex Adult
Reconstruction, Department of Orthopedic Surgery, Orlando Regional Medical
Center, Orlando, FL, USA
Robinson Pires, MD Federal University of Minas Gerais, Belo Horizonte, MG,
Brazil
Department of Orthopedic Trauma Surgery, Felicio Rocho Hospital, Belo Horizonte,
Brazil
Joshua Rozell, MD Department of Orthopedic Surgery, Hospital of the University
of Pennsylvania, Philadelphia, PA, USA
Michael R. Rutter, MD Department of Orthopedic Surgery, Geisinger Medical
Center, Danville, PA, USA
Adam A. Sassoon, MD, MS Department of Orthopedics and Sports Medicine,
Northwest Hospital University of Washington, Seattle, WA, USA
Peter J. Shekailo, MD Division of Orthopedic Trauma and Adult Reconstruction,
Department of Orthopedic Surgery, Orlando Regional Medical Center, Orlando, FL,
USA
Michael Suk, MD, JD, MPH, MBA Musculoskeletal Institute, Geisinger Health
System, Danville, PA, USA
Richard S. Yoon, MD Division of Orthopedic Trauma and Adult Reconstruction,
Part I
Before the Surgery
Chapter 1
General Consideration and Workup
of Periprosthetic Fractures
Matthew A. Frank and Hassan R. Mir
Periprosthetic fractures occur around or adjacent to prosthetic joints or orthopedic

implants. Currently, 0.8–1.1% of total hip arthroplasty (THA) and 0.5–1.1% of total
knee arthroplasty (TKA) patients will experience a periprosthetic fracture in the
first 5 years from surgery, and these numbers are expected to increase [1–5]. The
ever-expanding indications for THA are leading to more implants being placed in
younger as well as in older adults. The number of TKAs is also projected to increase
continuously [3, 6]. Increased life expectancy combined with the increased numbers
of arthroplasties is contributing to an overall increase in the number of peripros-
thetic fractures both in the United States and worldwide though periprosthetic frac-
ture rates appear to be a relatively constant proportion (4.2–7.4%) of an increasingly
large population of patients undergoing these primary and revision arthroplasty pro-
cedures [1]. Periprosthetic fractures are associated with significant morbidity and
mortality [7, 8]. Recent literature suggests a 6% 1-year mortality rate after peripros-
thetic femur fractures with age and type of surgery potentially influencing mortality
risk [7–9]. The majority of the deaths, 80%, occur within the first 3 months of sus-
taining the fracture [10]. Many treatment options exist for periprosthetic fractures
including nonoperative management, surgical management with plate fixation or
intramedullary fixation, nail/plate combination (NPC) constructs, and revision
arthroplasty [11].
The majority of periprosthetic fractures occur as a result of low energy/ground-
level falls [12]. Moreover, lower extremity fractures which are the focus of this book
M. A. Frank
Orthopedic Trauma and Reconstruction Service, North Mississippi Medical Center,
Orthopedic Trauma Clinic, Tupelo, MS, USA
H. R. Mir (*)
University of South Florida, Tampa, FL, USA
Florida Orthopedic Institute, Tampa, FL, USA
e-mail: hmir@floridaortho.com
© Springer Nature Switzerland AG 2019 3

F. A. Liporace, R. S. Yoon (eds.), Periprosthetic Fractures of the Hip and Knee,
https://doi.org/10.1007/978-3-319-43008-9_1
4 M. A. Frank and H. R. Mir
most often occur as events distinct from the perioperative period, whereas upper
extremity periprosthetic fractures tend to occur intraoperatively [13]. Several risk
factors have been described, including age, chronic steroid use, osteoporosis, rheu-
matoid arthritis, and Paget’s disease, which affect the quality and mechanical
strength of the host bone. Cementless implants, malposition of the components,
osteolysis, septic/aseptic loosening, and cortical stress risers also may lead to a
fracture [14, 15]. In addition to these, general factors such as female gender, higher
comorbidity, and higher ASA score are associated with a higher risk of peripros-
thetic fractures [15]. Several studies have found a high prevalence of osteopenia
(38–59%), associated with periprosthetic femoral fractures [16, 17]. Preoperative
bone mineral density or cortical thickness index may help to identify patients at risk
of this complication. In such patients, various prevention strategies should be estab-
lished, such as pharmacological treatment of osteoporosis or fall prevention.
Loosening of the prosthesis is a well-known risk factor. Lindahl et al. found that
70% of the implants in their study had become loose, and they established this fea-
ture as the most common cause of fractures [12]. By contrast, more recent studies
have identified aseptic loosening in less than 20% of cases [17]. Due to the fact that
a majority of these fractures occur in elderly patients, there is a high prevalence of
medical comorbidities. A Deyo–Charlson index of 2 or higher and ASA class of 3
or 4 were each independently associated with a 1.5–2.5 times higher risk of peri-
prosthetic fractures after primary THA, but these factors did not predict a poorer
outcome [15, 17]. It has been suggested that the type of fixation has an influence.
Specifically, Foster et al. found a significantly higher risk of periprosthetic femur
fractures in uncemented hemiarthroplasty vs. cemented hemiarthroplasty patients;
however, this has not been borne out in subsequent studies [17, 18].
Historically, the treatment of periprosthetic femoral fractures has been associ-
ated with a high rate of failure, complications, and poor outcomes [16]. These frac-
tures are a source of considerable morbidity in elderly patients. Specifically, multiple
studies show that age older than 85 years portends poor functional outcomes, greater
loss in the ability to perform activities of daily living, and increases the risk of mor-
tality [19, 20]. In a study of 336 community ambulators treated for hip fractures,
40% of patients required additional assistance ambulating, 12% become household
ambulators, and 8% became nonfunctional ambulators [21]. Age older than 85 years
was found to be an independent predictor of decline in ambulatory ability and of
becoming a household ambulator. In a similar study of 338 patients undergoing
operative treatment for hip fractures, age greater than 85 years was the only predic-
tor of failure to recover the ability to perform activities of daily living. Additionally,
many patients older than 85 years after losing the ability to ambulate remain living
in a skilled nursing facility at 1 year [21, 22]. Age older than 85 years was also a
significant predictor of mortality. Ruder et al. reported that 27% of patients older
than 85 years died before 1-year follow-up, compared to 18% for patients younger
than 85 years. In this patient subset, the 1-year mortality rate following peripros-
thetic distal femur fractures appears to be similar to that of hip fractures [22]. It is
clear that periprosthetic fractures occur in a high-risk population with a high mor-
bidity and mortality rate, especially in the octogenarian population.
1 General Consideration and Workup of Periprosthetic Fractures 5
Diagnostic Studies
The presence of periprosthetic fractures is most often self-evident. Typically, the

patient experiences an acute onset of pain accompanied by the inability to ambulate.
This is often in the setting of a traumatic event such as a fall. At times, the onset of
symptoms can be insidious in nature particularly when the underlying cause is
osteopenia or osteolysis. Clinical acumen is requisite to recognize these instances
before catastrophic failure occurs. Common sense dictates that once suspected, the
initial study performed include anteroposterior (AP) and lateral radiographs of the
joint in question. Additionally, full-length radiographs of the adjacent bones should
be obtained. Scrutiny of the condition of the surrounding bone is necessary to evalu-
ate for subtle signs of implant loosening, osteolysis, stress shielding, and poor bone
stock as well as mechanical alignment. Prosthetic replacement procedures can cause
a redistribution of the load where the stress to the distal femur is now transferred
through the metal stem, bypassing the femoral cortex. This stress shielding can
subsequently result in bone atrophy along areas of low mechanical loading.
Periprosthetic osteolysis after total hip arthroplasty, on the other hand, is believed to
be a result of a chronic inflammatory reaction to particulate wear debris or the
cement used in the fixation of the acetabular cup [23]. If possible, pre-fracture,
serial X-rays should be reviewed to help determine if there is previous evidence of
implant loosening or subsidence. Preoperative X-rays can be instrumental in defin-
ing the progression of osteolysis, the progression of cortical thinning/erosions, the
presence of notching, the condition of the cement mantle (when applicable), and the
formation of a distal pedestal.
It is equally important to recognize a well-fixed stem. A well-fixed stem is identi-
fied by noting signs of spot welding, proximal stress shielding in the setting of a
distally fixed stem, and proximal bone remodeling. Intraoperatively fractures can be
identified by abrupt change in pitch or the sound of cracking, a change in resistance
during broaching, or final implant impaction. When this occurs, it is crucial to per-
form intraoperative fluoroscopy or plain film radiography. Computed tomography
(CT) scans are becoming more useful in elucidating underlying bone stock espe-
cially with the advancement in two- and three-dimensional reconstruction algo-
rithms. The development of increasing accurate methodology for evaluating cortical
bone thickness has made CT scans all the more advantageous in the preoperative
setting [24]. Applying metal artifact removal software to the CT scans further
enhances the accuracy of these measurements [24].
Classification
Any effective classification system should be readily reproducible, and it should

establish a shared vernacular that effectively communicates the nature of the frac-
ture—location and severity—as well as prognosis and appropriate treatment
modalities. The initial systems used to classify periprosthetic factures were based
chiefly on the site of the fracture. One of the earliest classifications cited in the lit-
erature is by Parrish and Jones in 1964, who, in their nine-patient case series, clas-
sified patients into four groups based on the site of fracture (proximal, mid-shaft,
and distal femur) [25]. Numerous iterations proceeded this rudimentary classifica-
tion. Classification systems based on the site of the fracture alone do not provide
requisite guidance toward the best treatment option and certainly cannot be used in
isolation to determine the need for femoral component revision. Such classifica-
tions have also been shown to be inconsistent and difficult to reproduce [26, 27].
Periprosthetic fracture treatment decisions depend on five important factors: frac-
ture location, stability of the implant and fracture, quality of the host bone stock,
patient physiology and age, and surgeon experience [16]. These factors are used to
formulate a treatment algorithm. The numerous preceding periprosthetic fracture
classification systems, including those of Tower and Beals [28], Johansson et al.
[29], Bethea et al. [30], Cooke and Newman [31], and Roffman and Mendes [32],
were, with the exception of the last, based on the location of the fracture. The
Vancouver classification introduced by Duncan and Masri [33] combined the three
most important factors, namely, the site of the fracture, the stability of the implant,
and the quality of the surrounding bone stock to provide the surgeon with a useful
treatment algorithm (Table 1.1). This classification has been shown to be reliable
and valid [34]. While the Vancouver classification has been widely accepted for its
reproducibility, it does have some inherent weaknesses. For example, the treat-
ments of Vancouver B1 and C fractures are the same, although very distal C frac-
tures are often treated with a retrograde nail, whereas more proximal C fractures
require plate fixation. Similarly, the treatments of B2 and B3 fractures may be simi-
lar, with revision stem prostheses required along with the possibility of utilizing a
megaprosthesis or additional fixation distally. In the circumstance of a loose pros-
thesis, the surrounding bone usually has undergone resorption; now, it may be is at
increased risk of failure. A fracture in these cases is akin to a pathological fracture.
In general, the treatment of pathological fractures must address the underlying
pathology as well as the fracture if fracture healing is to be achieved. Therefore, it
Table 1.1 Vancouver classification of periprosthetic fractures

Type Site and characteristics of fracture
Type Fractures of the greater trochanter
AG
Type Fractures of the lesser trochanter
AL
Type Fractures at the level of or extending just below the stem with a solidly fixed stem
B1
Type Fractures at the level of or extending just below the stem with a loose component
B2
Type Fractures at the level of or extending just below the stem with a loose component and
B3 severe bone stock loss
Type C Fractures well distal to the stem
follows that treatment of a fracture secondary to a loose prosthesis requires revision

of the prosthesis. On the other hand, a fracture in a bone with a well-fixed prosthesis
following significant trauma requires treatment along the same principles as any
other fracture. The choice of treatment is thus determined primarily by whether or
not the prosthesis is well fixed, and only secondarily by the site of the fracture.
There are further detailed considerations that apply to various aspects of these frac-
tures [35–37].
A newer classification, the Baba classification (Fig. 1.1), predicts implant stabil-
ity based on the relationship between the implant design and fracture site employing
a completely new concept; fractures are divided into two types—with or without
use of cement—and each type is further divided into two subgroups [38]. Intuitively,
this makes sense as it addresses the method of implant fixation and correlates the
fixation type with fracture location to predict stability. In a study on the agreement
between the Vancouver classification-based judgment of plain, radiograms acquired
at the time of injury and actual surgical findings was 77–81% [39–41]. These values
are not as confidence inspiring as one would hope. On the other hand, the consis-
tency of Baba classification was very high, with reported rates as high as 95% [38].
Thus, the confirmation of stem stability during surgery is considered the gold stan-
dard and the most influential factor in optimizing outcome regardless of the classi-
fication system one chooses to employ [42, 43].
Fig. 1.1 Baba classification. (From Baba et al. [38]. With permission from Springer)
The first description of acetabular fractures around THA was by Miller in 1972
[44]. Nine cases of ischiopubic fractures were described after the use of five unce-
mented Ring components and four cemented McKee components in hip arthroplas-
ties [44, 45]. Stress fracture of the medial wall of the acetabulum after cementless
acetabular revision also has been described. There should be a high index of suspi-
cion in the situation of an elderly woman with an acute onset of symptoms after an
increase in her activity level because it may be a harbinger of pelvic discontinuity
[46]. Berry et al. reported a 0.9% prevalence of periacetabular fracture with pelvic
discontinuity at acetabular revision [47]. Associated factors seem to be trauma and
osteolysis. It is important to recognize pelvic discontinuity preoperatively so that
adequate implants and fixation devices are available at the time of surgery [48–50].
Berry et al. reported on a series of 27 patients with 31 hips with pelvic discontinuity
[47]. In that review, they described the diagnostic features of pelvic discontinuity.
These include any visible fractures on the AP radiographs, with rotation or transla-
tion of the inferior portion of the pelvis relative to the superior part. In some cases,
however, it is difficult to appreciate a fracture line because of obscuring hardware or
metallic implants. Judet views may be helpful, as they may show fracture lines
across the anterior and posterior columns as seen on the obturator and iliac oblique
radiographs. There will remain a small number of patients in whom this diagnosis
will be impossible to make preoperatively, and the surgeon will detect pelvic dis-
continuity intraoperatively. It is best always to assume that there is a chance of
encountering pelvic discontinuity when embarking on a revision THA with massive
associated acetabular bone loss and to be prepared to deal with it appropriately.
Although of little clinical utility as a classification system, Peterson and Lewallen
classified these fractures into Type I with a radiologically and clinically stable ace-
tabular component and Type II unstable component [49].
There is less agreement regarding the adoption of a universally accepted classifi-
cation system about total knee arthroplasty components. The Rorabeck classifica-
tion system places emphasis on the stability of the knee prosthesis and the
displacement of the fracture (Fig. 1.2) [51, 52]. The AO/OTA classification system
focuses on the location of the fracture on the distal femur and the complexity of the
fracture pattern [53]. The same principles as with the proximal femur dictate the
treatment options available to the orthopedic surgeon. The most frequently encoun-
tered fracture type is consistent with a Rorabeck Type II which entails a displaced
distal femur fracture associated with a stable implant [52, 54, 55].
On the tibial side, the Felix classification, first described in 1997, is based on
three factors, location of the fracture, stability of the implant, and timing of the
fracture (whether it occurred intraoperatively or postoperatively) (Fig. 1.3) [56].
Patella Fractures Epidemiology—The postoperative incidence is 0.3–5.4%
(reported as high as 21%). Risk factors include large central peg component, exces-
sive resection of the patella during prosthetic implantation; lateral release, with
devascularization of the patella; malalignment; thermal necrosis (secondary to exo-
thermic reaction associated with the methyl methacrylate use); and excessive femo-
ral component flexion. The Goldberg classification of periprosthetic tibial fractures
can be useful in directing treatment: Goldberg Type I (fractures not involving
cement/implant composite or quadriceps mechanism), Type II (fractures involving
I II III
Fig. 1.2 Lewis and Rorabeck classification—Type I: Stable, non-displaced, bone-prosthesis inter-
face remains intact. Type II: Displaced with an intact interface. Type III: Loose or failing prosthesis
irrespective of fracture displacement
I II III IV
Fig. 1.3 Felix classification—Type I: Occur in the tibial plateau. Type II: Adjacent to the stem.
Type III: Distal to the prosthesis. Type IV: Involve the tubercle. The stability of the implant is then
used to classify the fractures further: Subtype A is a well-fixed stem, subtype B is a loose stem, and
subtype C are intraoperative fractures
cement/implant composite and/or quadriceps mechanism), Type IIIA (inferior pole

fractures with patellar ligament disruption), Type IIIB (inferior pole fractures with-
out patellar ligament disruption), and Type IV (fracture-dislocations) [57].
Regardless which classification system one employs, it is evident that the exist-
ing construct, the fracture characteristic, and the host’s biological milieu must be
factored into formulating an effective treatment plan. A newer classification, pro-
posed to include interprosthetic fractures, will be addressed in a later chapter.
Evaluation/Diagnosis
The first step in the evaluation of periprosthetic fractures is a detailed history

including a detailed history of the implant, date of implantation, reoperation/revi-
sions, ambulatory status, cognitive status, recent illness/infections, living situation,
comorbidities, and antecedent pain. The presence of previous infection and/or ante-
cedent pain may indicate the presence of infection or aseptic loosening of the
implant. The presence of occult infection sometimes accompanies periprosthetic
fracture. The history should also include details regarding prior wound infections.
Culture reports should be sought in the medical records. Intravenous and oral anti-
biotic use should be documented, particularly if the patient remains on antibiotics
at the time of presentation. Problems with wound healing and episodes of soft tissue
breakdown should be documented. Other perioperative complications (venous
thrombosis, nerve or vessel injuries, etc.) should also be documented. Periprosthetic
fracture host evaluation should proceed with the same principles that guide the
treatment of osteomyelitis. Host deficiencies influence treatment options, progno-
sis, and the interpretation of the treatment results. The host must be able to heal the
fracture—when fracture fixation is performed—or tolerate revision surgery and
subsequent postoperative rehabilitation protocols. Cierny and Mader’s classifica-
tion can be a vital tool in guiding the surgeon’s evaluation of the patient. Their
classification examines the disability of the patient (Table 1.2). The functional
impairment caused by the fracture—and its underlying etiology—the reconstruc-
tion options, and the metabolic consequences of aggressive therapy influence the
selection of treatment candidates. Next, the physiologic classification (host) is eval-
uated. The condition of the host and the relative disability caused by the disease are
combined in a physiologic classification. A patient with a normal physiologic
response to infection and surgery is designated an A-Host; a compromised patient
is classified a B-Host and will have either local (BL), systemic (BS), or combined
Table 1.2 Cierny-Mader A-Host Robust immune system

classification
B-Host BL—compromised locally
B-Host BS—compromised systemically
C-Host Treatment worse than disease/not a good surgical
candidate
(BL,S) deficiency in wound healing. When the treatment or results of treatment are
more compromising to the patient than the disability caused by the disease itself,
the patient is classified a C-Host. Thus, the selection of surgical candidates may
vary from institution to institution until there has been a standardization of con-
cepts, methods, and techniques [58].
Workup
Routine laboratory work, including electrolytes and a complete blood count

(CBC) with differential, is useful for screening general health. The erythrocyte
sedimentation (ESR) rate and C-reactive protein (CRP) are useful concerning the
course of infection though they can be elevated in the face of acute injury/fracture.
If necessary, the nutritional status of the patient can be assessed via liver panels,
albumin levels, and transferrin levels. If wound-healing potential is in question, an
albumin level (3.0 g/dL or greater is preferred) and a total lymphocyte count
(>1500 cells/mm3 is preferred) can be obtained. For patients with a history of
multiple blood transfusions, a hepatitis panel and an HIV test may also be useful.
When infection is suspected, the joint may be aspirated or biopsied under fluoro-
scopic guidance. The aspirated or biopsied material is sent for a cell count and
gram staining, and cultures are done for aerobic, anaerobic, fungal, and acid-fast
bacillus organisms. To encourage the highest yield possible, all antibiotics should
be discontinued at least 2 weeks prior to aspiration. If fastidious organisms are
suspected, the cultures should be extended past the 5-day standard. When insuf-
ficiency fractures are suspected or when faced with a nonunion after periprosthetic
fixation, we advocate a thorough metabolic and endocrine workup that Brinker
et al. proposed in their 2007 article [59]. Initially, they recommend obtaining
25-hydroxyvitamin D and 1,25-dihydroxyvitamin D levels [59].
In the current milieu of widespread bisphosphonate use, an atypical fracture
should be excluded. Hallmark characteristics of atypical femur fractures (AFFs)
have been readily described in the literature, and they include lateral cortical
beaking, cortical hypertrophy, transverse lucency of the lateral cortex, transverse
orientation of the lateral cortex fracture, and minimal comminution [60–62]. Not
surprisingly, Tornetta’s multicenter retrospective review found that periprosthetic
atypical femoral fractures (PAFFs) had more complications than AFFs [60]. The
major difference between the AFF group and PAFF group occurred in time to union
(5 months vs 8 months), mortality (1% vs 10%), and complication rate (12% vs
25%) [60].
If a patient presents with radiologic features if impending PAFF but has mini-
mal pain, then a candid discussion must take place with the patient regarding the
risk of impending fracture and consideration for prophylactic plating. Regardless,
the patient must be closely monitored, bisphosphonates are discontinued, an endo-
crinology consultation obtained, and consideration of alternative medication, such
as teriparatide, is discussed [63–69]. If the patient presents with painful weight
bearing, but the X-rays are normal, a bone scan is indicated to detect an early stress
fracture. In addition, consideration must be given to protect weight bearing [70–
72]. As in the case of other stress fractures that are yet to manifest radiologically,
pain is the primary indication for protected weight bearing. If the bone scan con-
firms a developing fracture, bisphosphonates are discontinued, and alternative
medical therapy is explored [73]. Again, the patient is counseled regarding the risk
of fracture, including consideration of prophylactic fracture fixation to improve
stability. If the patient opts for nonoperative treatment, the patient is followed
closely in the outpatient setting to monitor symptoms, and repeated imaging is
obtained. If the X-rays show a lateral lucency, the patient should be counseled
regarding the risk of impending fracture, and surgical fixation with a long locked
plate should be considered with or without a strut graft [74, 75]. Bisphosphonates
are discontinued, and additional therapies such as teriparatide are considered in
consultation with an endocrinologist who specializes in metabolic bone disease.
A physical therapist should be consulted for preoperative and postoperative
training with respect to postoperative activity expectations and the use of assistive
or adaptive devices. The goals of immediate postoperative (inpatient) rehabilitation
include independent transfer and ambulation, when possible. Outpatient physical
therapy primarily addresses strength and range of motion of the surrounding joints
but may also include sterile or medicated whirlpool treatments to treat or prevent
minor infections (e.g., pin site irritation in patients treated with external fixation).
Occupational therapy is useful for activities of daily living and job-related tasks,
particularly those involving fine motor skills such as grooming, dressing, and the
use of hand tools. A nutritionist may be consulted for patients who are malnour-
ished or obese. Poor dietary intake of protein (albumin) or vitamins may contribute
to delayed fracture union and nonunion as well as delayed wound healing. A nutri-
tionist may also counsel severely obese patients to reduce body weight. Obesity
increases the technical demands of periprosthetic fracture treatment.
Concurrent Periprosthetic Fracture and Infection
In a recent article in Arthroplasty, the concomitant occurrence of periprosthetic

joint infection (PJI) and periprosthetic fracture was 11.6%, and hence, the surgeon
should consider PJI in the setting of a periprosthetic fracture, particularly if the
components are loose [76]. Chevillotte et al. in their series of 204 periprosthetic hip
fractures reported a similar prevalence of PJI (10.3%) [77].
Della Valle reports that the optimal cutoff values are similar to those used in
the diagnostic evaluation of chronic PJI, which are approximately 3000 WBC/uL
and 80% PMNs. Advantages of the synovial fluid WBC count and differential
include the ability to perform them either preoperatively or intraoperatively, their
low cost, objective nature, and the lack of need for specialized personnel or
equipment [76]. Intraoperative frozen histology is another option available to the
surgeon for the diagnosis of PJI. Munoz-Mahamud et al. concluded that histol-
ogy alone is not reliable for the diagnosis of PJI in Vancouver B2 periprosthetic
fractures. Their criterion for infection was 5 neutrophils per 400x field in at least
5 separate fields. In their study, 6 of 11 patients had positive histology, but only
2 of those 6 had positive cultures. This lead to a sensitivity of 100%, specificity
of 55.5%, positive predictive value of 33.3%, and negative predictive value of
100%. The false-positive rate was 66.6% [78]. In general, intraoperative frozen
section analysis is more costly than a synovial fluid WBC count and differential,
it is prone to sampling error, and it is both subjective and requires a skilled
pathologist which may not be available to all surgeons. In conclusion, Della Valle
finds that the synovial fluid WBC count and % PMNs are the best tests for diag-
nosing PJI and have similar cutoff values as when used for detecting PJI in
patients without a periprosthetic fracture. The ESR and CRP have poorer test
performance and can frequently be falsely positive, although they remain rela-
tively sensitive tests [76].
Currently the consensus position regarding the diagnosis of PJI is shown in
Table 1.3:
Table 1.3 Consensus position regarding the diagnosis of PJI [79]

Consensus—PJI is defined as:
Two positive periprosthetic cultures with phenotypically identical organisms
A sinus tract communicating with the joint
Having three or more of the following minor criteria
Elevated serum C-reactive protein (CRP) AND erythrocyte sedimentation rate (ESR)
Elevated synovial fluid white blood cell (WBC) count OR ++ change on leukocyte esterase
strip test
Elevated synovial fluid polymorphonuclear neutrophil percentage (PMN%)
Positive histological analysis of the periprosthetic tissue
Consensus—The approximate cutoffs listed below apply to tests obtained less than 6 weeks
from the most recent surgery:
No threshold for ESR could be determined as it is not useful ion the diagnosis of acute PJI
CRP >100 mg/L (knee and hip)
Synovial WBC count >10,000 cells/μL
Synovial PMN% >90%
Consensus—The approximate cutoff listed below apply to test obtained more than 6 weeks from
the most recent surgery:
ESR >30 mm/h
CRP >10 mg/L
Synovial WBC count >3000 cells per μL
Synovial PMN% >80%
Reprinted from Zmistowski et al. [79], with permission from Elsevier
Culture of multiple periprosthetic tissue samples is the current gold standard for
microbiological diagnosis of prosthetic joint infections (PJI). Additional diagnostic
information may be obtained through sonication fluid culture of explants. Implant
sonicate culture enhances the diagnostic assessment or PJI by identifying pathogens
that are inaccessible to traditional intraoperative tissue and synovial fluid cultures.
By amplifying the sampling of microbiologic cellular material, sonication improves
the sensitivity of cultures similarly as alternative methods such as polymerase chain
reaction or other molecular-based diagnostic methods while also providing antibi-
otic sensitivity testing [80–82].
However, it should be noted that current techniques can have relatively low sen-
sitivity (57%), with prior antimicrobial therapy and infection by fastidious organ-
isms influencing results [83]. A recent study demonstrates metagenomic sequencing
(i.e., sequencing of material recovered directly from environmental samples) can
provide accurate diagnostic information in PJI (sensitivity 97%) [83]. The increas-
ing availability of portable, random-access sequencing technology offers the poten-
tial to translate metagenomic sequencing into a rapid diagnostic tool in PJI [83]. As
a caveat, we note that when the surgeon determines that the clinical likelihood of
coincidental PJI is low, then there is an ill-defined role for the use of these highly
sensitive methods.
Alpha-defensin is another marker that has become prevalent in recent arthro-
plasty literature. Alpha (α)-defensin is composed of 29–35 amino acids; it is highly
concentrated in neutrophils and is secreted into the synovial fluid in response to
joint infection. A recent meta-analysis showed that synovial α-defensin has the best
sensitivity (0.92) and specificity (0.95) for PJI detection in laboratory examinations
[84]. The combination of synovial fluid α-defensin and CRP tests had a sensitivity
of 0.97 and a specificity of 1.00 [85]. The α-defensin test is a simple test that can be
performed before revision surgery. The test also responds to PJI with a wide spec-
trum of organisms and in different sites [86]. Moreover, the test is not affected by
prior antibiotic administration and systemic inflammation making it in many ways
superior to all traditional laboratory tests and helpful for the diagnosis of early PJI
[87, 88]. A new rapid α-defensin test for identifying PJI, called the Synovasure test
(Zimmer Inc., Warsaw, Indiana), is now commercially available. In a study of 50
patients the Synovasure test achieved a sensitivity of 69% and a specificity of 94%
[89]. For now this rapid test seems to be most useful as an adjunct, but it certainly
heralds more accurate and precise rapid testing modalities in the near future.
Periprosthetic fractures, in all mode of presentation, are challenging clinical sce-
narios. The orthopedic surgeon must be vigilant in their recognition, workup, and
surgical planning to achieve the best possible outcomes. The recognition of host
morbidity, prior functional status, fracture/bone milieu, and concomitant peripros-
thetic infection, coupled with the confirmation of stem stability, are essential factors
in the management of the periprosthetic fracture patient. Thorough imaging must be
obtained, and the proposed surgical intervention must be meticulously planned
ensuring all potentially necessary implants are available at the time of surgery.
Additionally, a multidisciplinary approach is necessary, and these professional rela-
tionships must be fostered to ensure proper communication and timely care. As our
population ages and the incidence of arthroplasties rapidly increase, it is important

for those that treat these fractures to stay abreast of the rapidly evolving diagnostic
technologies and treatment modalities. The ensuing chapters will elucidate specific
pitfalls, potential treatments, and future directions of periprosthetic fracture surgery
of the hip and knee.
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Part II
Periprosthetic Fractures About the Hip
Chapter 2
Management of Periprosthetic
Acetabular Fractures
Aaron J. Johnson and Theodore Manson
Introduction
There are three common scenarios where patients present with a periprosthetic ace-
tabular fracture (Fig. 2.1): intraoperative fracture, postoperative fracture due to a fall
or accident, and long-term pelvic discontinuity due to pelvic osteolysis. In this chap-
ter we will review management of an intraoperatively discovered periprosthetic ace-
tabular fracture as well as postoperative acetabular fractures due to a fall or accident.
Intraoperative Acetabular Fracture
Intraoperative acetabular fractures that occur during primary or revision hip replace-
ment are uncommon but present a challenge for acetabular fixation. One of the biggest
challenges is recognition that an intraoperative acetabular fracture has occurred, and
this is usually diagnosed by an acetabular component that does not achieve the expected
press-fit fixation or by an acetabular component that upon impaction protrudes much
more medially than would have been expected from the acetabular reaming.
If an acetabular fracture is suspected, the surgeon should:
1 . Remove the acetabular component.
2. Search for a displaced or nondisplaced fracture line in the acetabulum.
3. Obtain an intraoperative radiograph or fluoroscopic imaging of the pelvis.
Usually, these are equivalent to a Letournel transtectal transverse or subtectal
transverse acetabular fracture and can be easily diagnosed with acetabular
A. J. Johnson · T. Manson (*)

Department of Orthopedics, University of Maryland School of Medicine,
R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
e-mail: tmanson@umoa.umm.edu

https://doi.org/10.1007/978-3-319-43008-9_2
22 A. J. Johnson and T. Manson
Fig. 2.1 Injury films of a 68-year-old female who sustained a periprosthetic acetabulum fracture.
Anteroposterior, iliac, and obturator oblique films demonstrate a transverse-type fracture with cen-
tral protrusio of the acetabular components. (Used with permission from R. Adams Cowley Shock
Trauma Center)
c omponent removal. If there is any question, placing a Cobb elevator on the antero-
inferior iliac spine and a Cobb elevator on the ischium and distracting in between
these two points can determine whether a fracture is present.
I ntraoperative Acetabular Fracture with a Nondisplaced

Posterior Column Component
If, on inspection and intraoperative radiograph, the posterior column component

of the acetabular fracture is nondisplaced, then usually a multi-hole revision ace-
tabular component can manage this problem. Choosing a trial acetabular compo-
nent 2–4 mm larger than the last reamer size and impacting this into place will
usually give the surgeon an idea of the stability that will eventually be present with
2 Management of Periprosthetic Acetabular Fractures 23
the implanted acetabular component. The goal in this situation is to wedge the
acetabular component between the subchondral bone attached to the anteroinferior
iliac spine (AIIS) and the subchondral bone attached to the ischium (Fig. 2.2).
If reasonable stability results with a small amount of acetabular distraction, then
the surgeons should implant the same size acetabular component as the acetabular
trial and place multiple screws for fixation. It is important to choose the orientation
of the screw holes in the revision acetabular component to get long screws into the
ileum and then in addition one or more screws through the caudal aspect of the
acetabular component into the ischium.
We typically use intraoperative fluoroscopy to verify the position of these screws
and the orientation of the acetabular components.
In these cases, we typically restrict weight bearing for 6 weeks postopera-
tively while bony ingrowth occurs into the acetabular component with follow-up
radiographs every 2–4 weeks to make sure that there is no migration of the ace-
tabular component.
Fractures with a Displaced Posterior Column Component
Intraoperative acetabular fractures that result in posterior column displacement may

require additional fracture fixation in addition to acetabular component placement.
The displaced posterior column component or fractures where a pelvic distraction
technique does not result in a stable acetabular trial usually require supplemental
Fig. 2.2 Sawbones model of a pelvis illustrating the bony prominences between which bony sta-
bility should be achieved for stable acetabular component fixation. (Used with permission from
R. Adams Cowley Shock Trauma Center)
open reduction and internal fixation of the fracture line in addition to the implanta-
tion of an acetabular component.
We will describe the techniques for open reduction and internal fixation from
both the posterior and anterior approach to the hip; however, the surgeon should be
cautioned that this is an area where substantial experience with open reduction and
internal fixation of acetabular fractures is necessary. If this expertise does not exist
at the surgeon’s institution at the time of the intraoperative fracture, then attempts to
repair the acetabular fracture should be aborted.
Implantation of a temporary hemiarthroplasty can be considered as long as there
is not the potential for significant protrusio of the hemiarthroplasty component. If
protrusio of the hemiarthroplasty component is a concern, then the patient should be
left with a Girdlestone resection and transferred to a center experience with dealing
of acetabular fractures.
ombined ORIF and THA for Acetabular Fractures

C
Through the Kocher-Langenbeck Approach to the Hip
Setup, Implants, and Instrumentation
• Radiolucent table
• Fluoroscopic imaging
• Lateral hip positioners
• Posterior hip retractors
• Arthroplasty system of choice
• Multi-hole porous revision-style acetabular cups
• Long 3.5 mm cortical screws
• 3.5 mm pelvic reconstruction plates
• Plate benders
• 7.3 mm screws for posterior column fixation
• Femoral head autograft or allograft
The posterior Kocher-Langnbeck approach to combined ORIF and THA is use-
ful for fracture lines that involve displacement of the posterior column, transverse,
or T-type fractures. This approach is contraindicated when the patients have any
protrusio, medial dislocation of the femoral head or component, or if the AIIS is
disrupted.
When positioning, the patient should be lateral on a radiolucent table. The stan-
dard posterior Kocher-Langenback approach should then be performed to the hip.
Care should be taken to ensure the knee is flexed and the hip is extended to decrease
tension on the sciatic nerve. The gluteus maximum sling is also always taken down
to facilitate exposure.
Fracture fixation in this scenario is different than typical ORIF of acetabular
fractures that do not involve an acetabular prosthesis. It is not necessary to obtain
anatomic reduction of the acetabulum; rather, the goal of pelvic fixation here is to
achieve bony stability for cup fixation. Posterior column plates are used as needed
for stability. The author’s typical preference for fixation is long 3.5 mm screws and
3.5 mm pelvic reconstruction plates.
After the posterior column has been stabilized, proceed with arthroplasty. The
femur should be prepared first using standard femoral broaching and/or reaming
techniques, depending on the specific type of implant that will be used.
Attention should then be turned to the acetabulum. A C-shaped retractor should
be placed over the anterior edge of the acetabulum to retract the femur out of the
operative field. Should more exposure be needed, the reflected head of the rectus
femoris muscle may be taken down from its insertion.
The capsule and external rotators should be tagged, and this can be used as a
posterior retractor. Any debris should be cleared from the acetabulum, and then
reaming should begin. The first reamer should be 7 mm less than the final templated
acetabular size and should be used to medialize the cup placement. Subsequent
reamers should increase in size in 2 mm increments, and reaming is performed in
the final cup orientation.
The final reamer should be 1 mm less than the implanted cup size to allow for a
press-fit. The bone grafting should then be performed. Using the femoral head auto-
graft (if performing the procedure during primary THA) or allograft (if this is dur-
ing revision or if the native femoral head is not available), three different sizes of
bone graft should be morselized. Fill any defects in the pelvis, and use a reamer that
is 2 mm less than the implanted cup size to ream in reverse, in order to incorporate
the bone graft (Fig. 2.3).
Fig. 2.3 Intraoperative photographs of impaction grafting technique for acetabular defects. Three
difference bone sizes are combined with reverse reaming to create a “cobblestone” effect to pro-
vide support of the acetabular component. (Used with permission from R. Adams Cowley Shock
Trauma Center)
Fig. 2.4 Postoperative
radiographs demonstrating
posterior column plating
and acetabular component
with multiple screws for
revision THA and posterior
column fixation. (Used
with permission from
R. Adams Cowley Shock
Trauma Center)
The acetabular implant is then inserted. The authors’ preferred implant is a multi-
hole highly porous-coated revision-style cup. Three to five screws are placed in the
ilium and ischium. Medial screws may be placed with care if needed. Screws are
placed both above and below the equator of the cup in order to provide stability
against abduction failure before bony ingrowth can be achieved.
After implantation of the acetabular component, a trial headball is placed to
allow for assessment of component stability. The goal compound version in this
scenario is 40°, and the hip should be stable throughout a full range of motion,
including adduction and flexion. Standard methods for leg-length approximation
can be used to estimate leg length. Once the components are deemed stable and
implanted, radiographic or fluoroscopic images are obtained prior to closure to
ensure cup position and screw placement are accurate (Fig. 2.4). Anteroposterior
and Judet views are used.
The capsule and external rotators are then repaired using a #5 Ethibond suture.
The gluteal sling is repaired using #0 PDS suture, and the fascia lata is closed over
a 1/8″ drain placed to suction. Postoperatively, patients are kept touchdown weight
bearing for 3 months, at which time they may begin gradual resumption of full
weight bearing as tolerated. Once they are able to participate with physical therapy,
patients are taught posterior hip precautions and typically do not require any abduc-
tion brace.
ombined ORIF and THA for Acetabular

C
Fracture Through an Anterior Approach
Setup, Implants, and Instrumentation
• Radiolucent table
• Fluoroscopic imaging
• Anterior hip retractors
• Pelvic retractors
• Arthroplasty system of choice
• Multi-hole porous revision-style acetabular cups
• Long 3.5 mm cortical screws
• 3.5 mm pelvic reconstruction plates
• Plate benders
• 7.3 mm screws for posterior column fixation
• Femoral head autograft or allograft
When patients do not have sufficient intact bone at the AIIS in order to obtain a
press-fit, it is necessary to perform concomitant anterior stabilization as well as
revision THA. The preferred approach of the authors is a modified anterior Smith-
Peterson approach originally described by Levine [1, 2]. Levine described this tech-
nique in 1943 to address acetabular fractures with protrusio; it was further modified
by Beaule and Matta to allow for concomitant THA and ORIF [1]. This modified
approach provides excellent exposure to directly address any anterior fracture lines.
Should there be need for further fixation of the quadrilateral surface, this approach
and positioning also allows for addition of a separate incision for an anterior intra-
pelvic (Stoppa) approach, which is outside the scope of this discussion.
The standard setup at our institution is to use a flat-top radiolucent table. This
allows both legs to be draped, independent of any traction devices, and subsequently
gives an accurate intraoperative assessment of limb length comparison (Fig. 2.5).
Furthermore, the flat-top radiolucent table is preferred over traction setups because
most traction tables make imaging the acetabulum difficult if not impossible. The
patient is placed on stacks of blankets to elevate the torso, pelvis, and contralateral
nonoperative lower extremity (Fig. 2.6). Both extremities are then prepped into the
operative field (Fig. 2.7).
After positioning the patient as described above, a curvilinear incision is made
lateral to the ASIS. The incision begins distally approximately 7 cm in the direction
of the tensor fascia muscle fibers and continues proximally along the iliac crest
(Fig. 2.8). The distal aspect of the approach is similar to the direct anterior Smith-
Peterson approach. The superficial layer is through the fascia on the medial aspect
of the tensor fascia muscle belly (Fig. 2.9). This provides an additional layer of
protection for the lateral femoral cutaneous nerve. One through the deep fascia of
this muscle belly, the ascending branches of the lateral femoral circumflex system
are identified and cauterized. A capsulotomy is performed, and the anterior limb is
tagged with a suture to allow for anterior retraction. Alternatively, a capsulectomy
can be performed at this time.
After exposing the hip joint, dissection is carried proximally. The ilioinguinal
ligament is released subperiosteally (Fig. 2.10). Alternatively, an ASIS osteotomy
may be performed. If an osteotomy is not performed, the ligament is tagged with an
Ethibond suture to facilitate repair at the end of the case. After releasing iliacus off
the inner table, the hip and knee are flexed. This relieves tension off of the neurovas-
cular structures in order to safely place retractors into the true pelvis (Fig. 2.11).
Although rarely needed, an AIIS osteotomy may now be performed to release the
rectus femoris insertion.
Fig. 2.5 Intraoperative
assessment of limb length
comparison. Direct
comparison can be made
while ensuring that both
feet are directly beneath
the pubic symphysis, and
both the medial malleolus
and heel can be used for
comparison. (Used with
permission from R. Adams
Cowley Shock Trauma
Center)
Fig. 2.6 Radiolucent table demonstrating stacked blankets to elevate the head, torso, and pelvis.
This allows for intraoperative hip extension to facilitate exposure. The contralateral limb may be
placed on a padded mayo throughout the case to avoid contralateral hip extension if desired. (Used
with permission from R. Adams Cowley Shock Trauma Center)
Fig. 2.7 The patient is positioned on the radiolucent table supine with both legs prepared into the
operative field. (Used with permission from R. Adams Cowley Shock Trauma Center)
Fig. 2.8 A curvilinear

incision is made with the
distal extent in line with
the fibers of the tensor
fascia muscle and
proximally along the iliac
crest. (Used with
permission from R. Adams
Cowley Shock Trauma
Center)
The next aspect of the case is to achieve bony stability of the pelvis. Unlike
acetabular ORIF of the native hip, anatomic reduction here is not necessary. The
goal is to provide a stable buttress for the acetabular arthroplasty component.
Consequently, a 3.5 mm pelvic reconstruction plate is usually sufficient, with screws
placed parallel to the quadrilateral surface just medial to the cotyloid fossa.
Additionally, long 3.5 mm screws may be placed into the posterior column. This can
provide additional stability, or fixation for nondisplaced posterior column fractures
(Fig. 2.12).
After the pelvis has been stabilized, acetabular component preparation proceeds
as described in the previous section.
Fig. 2.9 Superficial
dissection showing the
fascial incision through the
tensor fascia and exposed
fibers of the tensor fascia
muscle belly. (Used with
permission from R Adams
Cowley Shock Trauma
Center)
Fig. 2.10 Subperiosteal
release and tagging of the
inguinal ligament.
Alternatively, an ASIS
osteotomy may be
performed at this stage and
later repaired with a
3.5 mm lag screw. (Used
with permission from R
Adams Cowley Shock
Trauma Center)
Fig. 2.11 Intraoperative
view of the hip
capsulotomy and the inner
table, allowing for
placement of intrapelvic
retractors into the true
pelvis after reflection of
the inguinal ligament.
(Used with permission
from R Adams Cowley
Shock Trauma Center)
Fig. 2.12 (a, b) are postoperative anteroposterior, iliac, and obturator oblique views demonstrat-
ing a revision multi-hole acetabular component with screw placement in addition to anterior col-
umn fixation. There are two long 3.5 mm screws through the plate into the posterior column.
Additionally, note the ASIS and AIIS osteotomies that have been performed to aid in exposure and
visualization during the approach. (Used with permission from R Adams Cowley Shock Trauma
Center)
Similar to a direct anterior approach, the femoral preparation is the more difficult
aspect of the case. Having the torse and pelvis elevated on stacked towels allows for
adequate hyperextension of the hip to elevate the femur anteriorly. Standard
posterior releases should be performed as needed to aid in femoral exposure. This
includes elevating the ischiofemoral ligament from the femoral “saddle,” at the con-
fluence of the femoral neck and greater trochanter. Continue with femoral prepara-
tion according the implant of choice.
Components are then trialed and implanted. The authors typically preserve the
capsule and repair it at this time with #5 Ethibond sutures to the undersurface of the
gluteus medius tendon. If the inguinal ligament was taken down, it is now repaired
subperiosteally with #5 Ethibond suture; alternatively, if an ASIS osteotomy was
performed, it is repaired with a 3.5 mm lag screw. The closure is continued in a
layered fashion over drains.
Postoperative care is the same as for the posterior approach. Weight bearing is
protected for a minimum of 3 months after surgery, at which time the patients may
progressively relinquish walking aids as able.
utcomes After ORIF and THA for Periprosthetic

O
Acetabular Fractures
Complications after this procedure are similar to those after total hip arthroplasty.
They include dislocation, infection, heterotopic ossification, limb length discrep-
ancy, and thromboembolic events. Additional complications include nonunion of
the acetabular fracture and late instability from component subsidence [3, 4–8].
Heterotopic ossification is a common problem after acetabular surgery. A meta-
analysis from 2013 reported an average rate of HO following THA for acetabular
fractures to 38% [9]. Some authors believe it is more common after posterior and
extensile approaches than anterior. At our institution, it is common practice for pos-
terior acetabular approaches to receive postoperative single-dose radiation therapy
for the prevention of HO.
Reported dislocation rates after ORIF and THA for acetabular fractures are
higher than for standard hip arthroplasty [8]. Reports range from 2% to 4% in the
literature [10]. Patients are taught posterior hip precautions after a posterior
approach. However, patients do not typically need any abduction brace provided
they are able to comply with precautions. We also make every effort to stabilize the
components when placed from a posterior approach with appropriate compound
version and perform a dynamic repair of the capsule and external rotators to the
gluteus medius tendon to maximize stability.
Take-Home Points
Periprosthetic acetabular fractures are challenging fractures to treat. They require a

combination of skills to adequately understand and reconstruct the pelvis for bony
stability and perform revision hip arthroplasty. Approaches should coincide with
desired fixation/revision strategy. Outcomes after this procedure are similar to those
after revision total hip arthroplasty but may have an extended rehabilitation and
recovery period for the patient due to the prolonged period of protected weight bear-
ing [11, 5, 6]. Goals of procedures should focus on early weight bearing and mobi-
lization to minimize morbidity and mortality [4]. Performing these cases require
planning, experience, and efficiency to minimize complication risk. These proce-
dures should only be performed at institutions where adequate expertise is present
in both fields and may often require two surgical teams: one for pelvic fixation and
one for revision arthroplasty.
References
1. Beaule PE, Griffin DB, Matta JM. The Levine anterior approach for total hip replacement as
the treatment for an acute acetabular fracture. J Orthop Trauma. 2004;18:623–9.
2. Levine MA. A treatment of central fractures of the acetabulum. J Bone Joint Surg. 1943;XXV:5.
3. Carroll EA, Huber FG, Goldman AT, et al. Treatment of acetabular fractures in an older popu-
lation. J Orthop Trauma. 2010;24:637–44.
4. Matta JM. The goal of acetabular fracture surgery. J Orthop Trauma. 1996;10:586.
5. Mears DC. Surgical treatment of acetabular fractures in elderly patients with osteoporotic
bone. J Am Acad Orthop Surg. 1999;7:128–41.
6. Mears DC, Velyvis JH, Chang CP. Displaced acetabular fractures managed operatively: indica-
tors of outcome. Clin Orthop Relat Res. 2003;407:173–86.
7. Sheth D, Cafri G, Inacio MC, Paxton EW, Namba RS. Anterior and anterolateral approaches
for THA are associated with lower dislocation risk without higher revision risk. Clin Orthop
Relat Res. 2015;473:3401–8.
8. Weber M, Berry DJ, Harmsen WS. Total hip arthroplasty after operative treatment of an ace-
tabular fracture. J Bone Joint Surg Am. 1998;80:1295–305.
9. Chemaly O, Hebert-Davies J, Rouleau DM, Benoit B, Laflamme GY. Heterotopic ossification
following total hip replacement for acetabular fractures. Bone Joint J. 2013;95-B:95–100.
10. Jimenez ML, Tile M, Schenk RS. Total hip replacement after acetabular fracture. Orthop Clin
North Am. 1997;28:435–46.
11. Kreder HJ, Rozen N, Borkhoff CM, et al. Determinants of functional outcome after simple and
complex acetabular fractures involving the posterior wall. J Bone Joint Surg. 2006;88:776–82.
Chapter 3
Periprosthetic Fractures About
the Acetabulum: Management
of the Loose Component
Tori A. Edmiston, P. Maxwell Courtney, and Brett R. Levine
Introduction
Periprosthetic acetabular fractures are rare and difficult injuries to manage follow-
ing total hip arthroplasty (THA). They may occur in the early postoperative period,
during surgery or, at long-term follow-up. The complexity of these fractures is com-
pounded by varying local concerns including component stability, prior bone
removal (unknown during primary procedure), retro-acetabular osteolysis, and peri-
prosthetic stress shielding. The timeframe in which a periprosthetic acetabular frac-
ture occurs often gives some hint as to the potential etiology of the injury. The initial
description of acetabular fractures in patients with a THA were first reported in
1972, with all cases treated non-operatively going onto nonunion and a subsequent
resection arthroplasty [1]. While historically periprosthetic acetabular fractures had
poor outcomes, newer implant technology and refined revision arthroplasty and
fracture management principles have improved outcomes for these patients.
The dramatic increase in utilization of cementless acetabular components in pri-
mary THA may explain the noted rise in periprosthetic acetabular fractures over the
past couple of decades. This chapter will highlight the incidence, etiology, classifi-
cation, and management strategies for periprosthetic acetabular fractures. While
large, prospective studies are lacking in the literature, we will also review the current
data documenting outcomes following periprosthetic acetabular fractures as well as
various ways to treat such injuries. With the growing number of THA procedures
T. A. Edmiston · B. R. Levine (*)

Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
e-mail: Brett.levine@rushortho.com
P. M. Courtney
Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
Rothman Institute, Philadelphia, PA, USA

https://doi.org/10.1007/978-3-319-43008-9_3
36 T. A. Edmiston et al.
performed in the United States each year coupled with a younger, more active patient
population, orthopedic surgeons will likely see a rise in these injuries in the future.
Incidence
Intraoperative periprosthetic acetabular fractures are likely underreported in the litera-

ture. Historically such fractures have been reported to occur in less than 1% of THA
cases [2, 3]. Haidukewych et al. found an incidence of 0.4% of acetabular fractures
with an uncemented component discovered during the index procedure [4]. A more
recent study, however, found that the incidence of occult periprosthetic fractures of the
acetabulum may be higher than we have thought, with fractures found in 8.4% of 486
primary THA procedures found on postoperative CT scans [5]. Based upon clinical
experience, intraoperative fractures likely occur between 2% and 4% of the time as a
minor injury that goes unnoticed around a stable acetabular implant. More commonly
(~2–3%), the fracture is of a peripheral wall (or peripheral osteophyte) of seemingly
little consequence with no impact on component stability or management. In a smaller
percent of cases (<1%), the fracture may be recognized during the index procedure
and necessitate conversion to a different cup and/or plating of the fracture.
The incidence of early or late postoperative periprosthetic acetabular fractures is
difficult to accurately measure. Difficulty in coding and diagnosing these injuries has
made it hard to determine the exact incidence of periprosthetic acetabular fractures
after a primary THA. One study documented the overall incidence of early or late
fractures at 0.07% [6]. In another contemporary study, periprosthetic acetabular frac-
tures represented 3.8% of all hip revisions [7]. The remainder of the data found in the
current literature are only represented by small case series and case reports [8–13].
Etiology
The etiology of periprosthetic acetabular fractures varies and depends largely on

timing of the fracture [14]. Causes of periprosthetic fractures occurring intraopera-
tively include cementless fixation, excessive reaming, malpositioned retractors,
BMI greater than 40 kg/m2, and abnormal bone quality found in patients with rheu-
matoid arthritis, Paget’s disease, osteoporosis, or prior pelvic radiation [7, 16–17].
The superolateral wall is the most frequent location for an occult periprosthetic
fracture of the acetabulum [5]. Prior to cementless fixation, intraoperative fractures
of cemented acetabular components were almost nonexistent. In cadaveric models
it has been shown that underreaming by 2 mm can lead to an approximately 13%
incidence of fracture, and with 4 mm this increases to 54% [18]. Acetabular frac-
tures may also occur from overzealous reaming and/or forceful impaction of the
cup, often seen with monoblock and cobalt-chromium cups [19, 15]. Elliptical
monoblock cups have been shown to have the highest rate of fracture at 3.5% versus
a 0.09% fracture rate attributed to hemispherical modular shells [4].
3 Periprosthetic Fractures About the Acetabulum: Management of the Loose Component 37
Postoperative periprosthetic acetabular fractures can also occur in the early or late
timeframe after the index procedure. These fractures are typically caused by poor
implant design, missed intraoperative fractures, trauma, and acetabular bone loss for
any reason. Osteolysis, stress shielding, and adverse local tissue reactions to byprod-
ucts of THA have been implicated in etiology for acetabular bone loss. Missed intra-
operative fractures may become more readily apparent after the surgery when the
patient begins to mobilize. Bone loss for any reason leads to an increased risk for
spontaneous or low-energy fractures. Alternatively, some implant designs have not
had as much success with osseointegration leading to early loosening, component
migration, and/or subsequent acetabular fracture (Fig. 3.1). These types of fractures
tend to be more difficult to manage in that they may be larger than they appear and
are classically associated with bony acetabular defects. A summary of etiology of
periprosthetic acetabular fractures based upon timing is detailed in Table 3.1.
a b
Fig. 3.1 Cup migration into the pelvis after revision THA for polyethylene wear. (a) Intraoperatively
acetabular cup was revised and a new acetabular implant inserted without sufficient bony bed; no
screws were used resulting in early migration of the cup into the pelvis. (b) Patient subsequently
required another revision of the acetabular component due to a loose acetabular component, pelvic
discontinuity, and periprosthetic acetabular fracture. Multiple buttress augments and bone grafting
were necessary due to severity of the bone defects from reaming, osteolysis, and prior stress shielding
Table 3.1 Periprosthetic acetabular fracture causes—temporal relationship of etiology

Intraoperative Early postoperative Late postoperative
Aggressive impaction of the Loosening of the component and Acetabular bone loss
acetabular component subsequent fracture Osteolysis
Underreaming >2 mm Poor design (poor track Stress shielding
Stiff material components record) Adverse local tissue
Eccentric reaming Less than ideal insertion reactions
Over-reaming
Excessive retraction can create Trauma Periprosthetic stress
iatrogenic wall fractures fracture
Missed intraoperative fracture Trauma
Diagnosis
Typically, the diagnosis of an acute periprosthetic acetabular fracture will occur on

routine plain radiography. This includes an AP pelvis, AP, frog lateral, and shoot-thru
lateral of the affected hip. Judet views or a false profile view can be ordered to help
identify more subtle fractures and to better assess the column integrity. Most often
with a detailed analysis, these are all the tests necessary to appropriately classify
your acetabular fracture and adjacent bony defects. Serial radiographs are helpful to
assess component stability and prior bone stock. CT scans can be utilized to assess
retro-acetabular osteolysis, adjacent pelvic injuries, and a more detailed look at the
fracture pattern if necessary (when in doubt more information is always a good idea).
In the acute setting, nuclear imaging may have a difficult time distinguishing between
a loose implant and local fracture, and its use is not recommended routinely. MRI
and additional advanced imaging techniques are often unnecessary to classify the
injury and have little impact on the ultimate decision tree that is followed.
Classification Systems
There are several classification systems in the literature for periprosthetic acetabular
fractures. Most will focus on component stability, bone stock, and column integrity
as these factors directly impact the management of the fracture and acetabular com-
ponent. A good classification system is developed to help guide management with
high inter- and intra-observer reliability. However, at present, there remains no con-
sensus as to the “best” classification to follow, and the authors suggest following the
one that an individual surgeon feels most reliably helps guide treatment decisions.
Peterson and Lewallen first reported relatively poor results in their 11 patients with
periprosthetic fracture of the acetabulum [6]. They initially classified these fractures
into two categories: Type I, the acetabulum component was clinically and radio-
graphically stable, and Type II—the component was loose. Component stability
remains one of the crucial points to any classification system of periprosthetic ace-
tabular fractures and is typically the first branch of the decision tree in managing
these cases. These fractures can further be classified based upon their timing: includ-
ing intraoperative, early postoperative and late postoperative. Other periprosthetic
acetabular fracture classification systems reported in the literature are detailed below.
Della Valle Classification [20]
• Type I Fracture—occurs intraoperatively at the time of component insertion

–– Type A: Non-displaced with a stable acetabular component.
–– Type B: Diagnosed intraoperatively with a displaced fracture.
–– Type C: Fracture is diagnosed postoperatively.
• Type II Fracture—occurs at the time of component removal

–– Type A: Associated with less than 50% host bone loss
–– Type B: Associated with greater than 50% host bone loss
• Type III Fracture—traumatic fracture
–– Type A: Component stable
–– Type B: Component unstable
• Type IV—spontaneous
–– Type A: Less than 50% bone stock loss
–– Type B: Greater than 50% bone stock loss
• Type V—pelvic discontinuity
–– Type A: Less than 50% bone stock loss
–– Type B: Greater than 50% bone stock loss
–– Type C: Associated with pelvic radiation
Callaghan classified the fractures into four types for intraoperative
fractures [21]
• Anterior wall
• Transverse
• Inferior lip
• Posterior wall
Davidson et al.—Vancouver Classification Modification [22]
• Type I—Nondisplaced fracture with a stable component
• Type II—Nondisplaced fracture that compromises the stability of the
reconstruction
• Type III—A displaced fracture
Duncan et al.—Unified Classification System (AO Classification) [23]
• Type IV6—Periprosthetic pelvic fracture
–– A—Fracture of the apophysis or bone with soft-tissue attachment (ASIS/
AIIS = A1, Ischial apophysis = A2)
–– B—Fracture of the peri-acetabular bone, adjacent to the implant
• B1 = well-fixed cup
• B2 = loose implant
• B3 = loose implant with poor bone quality
–– C—Fracture in the bone containing the cup, but not in the retro/peri-acetabular
area
–– D—Fracture of one bone that supports bilateral replacements
–– E—Fracture of two bones supporting one replacement
–– F—Fracture involves the joint surface, which was not replaced but articulates
with the implant
Some early and most late periprosthetic fractures are associated with significant
bony defects. Understanding bone defects in late fractures is crucial as this will
often guide and change one’s treatment plan. Acute fractures are drastically differ-
ent than those that occur late in the setting of osteolysis and local stress shielding.
The latter often affords little possibility of primary bone healing, particularly when
there is significant retro-acetabular osteolysis. Revision THA principles should be
followed as well as treatment guidelines as outlined in the Paprosky classification
which is detailed below [20].
Paprosky Classification
Surrogate markers for acetabular bone:

1. Kohler’s line
A. Integrity of medial wall and superior anterior column
2. Ischial lysis
A. Integrity of the posterior wall and posterior column
3. Tear drop
A. Integrity of medial wall and inferior portion of anterior and posterior

column
4. Vertical migration
A. Integrity of superior dome
Type I
(a) No significant migration is noted.
(b) No ischial osteolysis.
(c) No osteolysis of the teardrop.
(d) Kohler’s line has not been violated.
Type II
(e) <3 cm superior migration proximal to the superior obturator line.
(f) No substantial ischial osteolysis (<7 mm distal to obturator line).
(g) Minimal teardrop osteolysis.
(h) Pattern of medial migration varies with subclassification into A, B, and C
categories:
(i) IIA: Superior and medial bone loss
(ii) IIB: Not contained and <1/3 of superior rim is affected
(iii) IIC: Medial bone loss
At least 50% host bone contact with cup
Type III
Type IIIA Defect
• More than 40–60% of surface area for cup.
• “Up and out” defect.
• Migration >3 cm from teardrop
• Ischial lysis is mild to moderate.
• Partial destruction of teardrop.
• Ilioischial and iliopubic lines are intact.
Type IIIB Defect
• <40% surface area for cup-bone contact.
• “Up and in” defect.
• Migration >3 cm from teardrop.
• Ischial lysis is extensive.
• Destruction of teardrop.
• Migration medial to the Kohler line.
• Possible discontinuity.
Management (Table 3.2)
Treating these injuries can be difficult, and it is important to determine first if the
component is loose or not. If the component is not loose, then the injury can be
treated more like a fracture, whereas if the implant has migrated, then revision THA
principles will need to be followed. Despite seeking the same goal of anatomic
reduction and restoration of function, fracture management is drastically different
than are revision THA principles. One of the most crucial factors in management
and outcomes is the integrity of the acetabular columns. Unlike the native hip, col-
umn integrity must be fully assessed intraoperatively as there may be osteolysis
and/or stress shielding and the components themselves often hide the extent and
severity of the acetabular damage. To summarize the treatment algorithm (Fig. 3.2),
it is best to classify the fracture by timing, component stability, and then column
integrity and remaining bone stock.
Table 3.2 Periprosthetic acetabular fracture management options

Observation Only Acetabular Revision and fracture fixation
Early post-op, non-displaced Early post-op, displaced or non-stable component, late post-op
TBWD (protected) for Addition of acetabular screws
8–12 weeks and watch closely Consider upgrading to “jumbo cup”
ORIF of acetabular fracture with revision of the acetabular
component
Consider addition of bone graft from reamings if poor bone stock
TDWB (protected) for 8–12 weeks
42
Acetabular
Periprosthetic
Fractures
Peri-operative Traumatic Osteolytic
Stable Unstable Poor

Good
Stable Unstable bone
bone
quality quality
Protected Column plating,
weight protrusion rings, highly
Screw porous metal cup
fixation of Column plating,
cup revision cup Wedges, triflange
Fracture Fracture non- Compression by implants, highly porous
consolidated consolidated column plating or metal cup, cup cage
protrusion ring constructs, socket cups
OR
Secondary Distraction by triflange
Stable loosening of implants or jumbo cup
Small, Large, non-
cup contained contained defect
defect
Revision cup
Allogenous bone Bone graft or wedges,
graft, revision cup triflangeimplants, highly
porous metal cups
Fig. 3.2 Management algorithm

T. A. Edmiston et al.
Case 1
A 72-year-old female with a history of a left THA 2 years ago presented pain in her
left hip and two episodes of instability. Radiographs demonstrated a retroverted
acetabular component, and laboratory markers were negative for infection, Fig. 3.3a.
She elected to undergo an acetabular revision. Intraoperatively, she sustained a peri-
prosthetic acetabular fracture during impaction of the component. The acetabular
cup was found to be grossly unstable intraoperatively.
Intraoperative fractures are often caused by forceful impaction of the component
and typically go unnoticed during the procedure. The most common fracture pattern
is peripheral rim injuries; however, column and transverse fractures can occur [24].
If unrecognized, these fractures can propagate leading to cup migration, protrusion,
or even frank pelvic discontinuity. Therefore, even in benign-appearing revision and
primary cases, it is important to avoid excessive retraction or inadvertent placement
of peri-acetabular retractors to avoid an iatrogenic wall or even worse a column
fracture. A high index of suspicion and recognition of fracture is key. If the acetabu-
lar component is stable with a non-displaced fracture, the surgeon may leave cup in
situ and protect the patient’s weight bearing postoperatively. If the component is
unstable, the surgeon can consider open reduction and internal fixation of the frac-
ture using a pelvic reconstruction plate (Fig. 3.3b), using the femoral head as auto-
graft and implanting a multihole hemispherical cup and placing supplemental screw
fixation. It is important to achieve anterosuperior and posteroinferior fixation to the
pelvis with the acetabular component. As a last resort for an acute pelvic discontinu-
ity, a cup cage construct can be considered. Postoperatively protocols should include
keeping patient’s touchdown weight bearing for 6–12 weeks with close clinical and
radiographic follow-up.
a b
Fig. 3.3 (a) Anteroposterior pelvis radiograph postoperatively following an intraoperative left

periprosthetic acetabular fracture. (b) The patient returned to the OR the following morning and
underwent ORIF of her posterior column with placement of a multihole hemispherical cup
Case 2
A 47-year-old female who underwent a THA with subsequent revision within the
first 48 h of her surgery for instability of the hip. A fracture of the pelvis was noted
during the cup revision but was elected to be treated non-operatively. Over the next
8 months, the patient had continued pain and migration of the acetabular component
into her pelvis (Fig. 3.4a, b).
In acute periprosthetic acetabular fractures in the early postoperative period,
component stability must also be assessed. In this patient, the acetabular compo-
nent was initially revised and felt to be stable despite a pelvic fracture. The cup
subsequently migrated into the pelvis and at our revision was found to be unstable
intraoperatively. Fixation was achieved with a revision shell with multiple screws
on each side of the defect, Fig. 3.4c. Morcellized allograft was used fill the large
medial defect with later consolidation on follow-up radiographs, Fig. 3.4c. Bone
grafting to reconstitute pelvic bone stock is a viable option; however, the cup must
remain stable and osseointegrate for this technique to be successful. In this case,
the defect was partially contained by a reactive sclerotic rim of bone to encom-
passed the graft and allow for consolidation. If the defect is not contained, then it is
more difficult to use morcellized graft in this setting. With a loose acetabular com-
ponent, treatment modalities consist of revision to a jumbo cup with or without
plating and/or acetabular augments. A cup cage construct can be utilized as well as
structural allograft with a cage or a custom triflange component. Irrespective of
treatment modalities, protected weight bearing is key with progression to weight
bearing as tolerated at 10–12 weeks, as always close clinical and radiographic fol-
low-up is recommended.
Case 3
A 73-year-old female presented with atraumatic left hip pain after a primary
THA. She was in a rehab facility when the pain worsened and transferred for defini-
tive management of an acute pelvic discontinuity. Preoperative radiographs show
component migration into the pelvis; however, what was not appreciated was the
substantial posterior column bone loss from eccentric reaming during the primary
procedure.
In late postoperative periprosthetic acetabular fractures, patients typically pres-
ent with osteolysis and stress shielding. Surgeons should beware that adjacent bone
may be of poor quality and defects may seem larger than they appear. Fracture
management principles with plate osteosynthesis has little role in these patients and
should be addressed with revision arthroplasty under the acetabular defect system.
If chosen to undergo revision surgery, surgeons should be cautious with acetabular
reaming as there is limited bone stock. Fixation of the acetabular component to
a b
Fig. 3.4 (a, b) Preoperative radiographs demonstrating an acute periprosthetic fracture that was
treated non-operatively and subsequently migrated into the pelvis. (c) Postoperative radiographs
demonstrating treatment of a periprosthetic fracture, pelvic discontinuity, and loosening of the
acetabular component. The patient underwent revision THA with curettage and bone grafting of a
large acetabular defect using allograft
both the superior and inferior half of pelvis is necessary to achieve a good result,
Fig. 3.5. In some cases, the surgeon may need to treat bone loss and fracture sepa-
rately. Options include graft/augment the lysis, fixation of the fracture (may be
necessary to stage the procedures), or acetabular distraction if the fracture is not
likely to heal. The surgeon should underream the acetabulum by 4–8 mm, wedge
the cup, and distract hemipelvis. Ligamentous tension will allow the surgeon to
a b
Fig. 3.5 (a, b) Preoperative radiographs of a patient who sustained a late periprosthetic acetabular
fracture with protrusion into her pelvis. (c) Postoperative radiographs of a patient who sustained a
late periprosthetic acetabular fracture with protrusion into her pelvis. This patient was best served
with revision arthroplasty to treat acetabular bone loss using multiple augments, buttress augment
posterosuperiorly, a jumbo multihole hemispherical cup with multiple screws, and morcellized
cancellous allograft
obtain a press-fit and use cup as internal plate. Stable implants can be left to heal
non-operatively although many require revision down the road as reported by
Petersen and Lewallen [6].
Regardless of fracture or arthroplasty management principles, the overall goal is
to maximize the function of the hip and minimize the potential for intraoperative or
future complications. The basic goals are to achieve fixation of the fractured column,
restore the center of rotation, reduce the fracture as possible, and fill the gaps when
needed. The underlying principle of treating periprosthetic acetabular fractures is that
the columns must be sufficiently stable to support an acetabular implant and prevent
any mobility at the bone implant interface. To achieve proper implant insertion, there
must also be sufficient bone available either non-augmented or augmented.
Outcomes
Outcomes of previous publications are as listed below (Table 3.3):

• Sharkey and colleagues reported on 13 fractures with 6 being treated by addi-
tional screw fixation. One other was deemed a stable fracture pattern and treated
with activity modification and protected weight bearing. Two others were treated
without any alterations to the postoperative protocol. Of the four found
postoperatively, they all showed radiographic evidence of loosening, and two
required revision surgery [25].
• Peterson and Lewallen recommend trialing non-operative treatment with stable
implants; however, 80% of these patients required revision surgery [6].
• Barlow et al. (2015), 63 patients >24 months FU with custom triflange, 13.5%
failure rate, trend to lateralize hip center [26].
• Triflange studies: ~60–80% success rates. Instability, nerve injury, and complica-
tions are not uncommon [27].
• Meneghini et al. (2015): eight cases with buttress augment, one iliac wing frac-
ture, 16.5 month FU, no revisions [28].
• Brown et al. (2015), Figure 7 grafts, 72% survivorship at 25-year FU, all Type
IIIA defects [29].
• Zazgyva et al. (2015): 29 hips with 4.8-year follow-up, reinforcement ring
and bone graft, maintained medial wall bone stock, 85.2% survival rates at
10 years [30].
• Mao et al. (2015): Custom cages, no revisions, and no radiographic migration of
the cup; one cup appears loose at mean follow-up of 67 months [31].
Complications
As with any surgery complications are always a possibility. Cited complications

include nonunion, additional revision surgery for any reason, instability, nerve
injury, loosening, infection, hemorrhage, and implant failure. Instability, nerve
injury, and other complications are especially not uncommon in these complex
cases. Getting a handle on exact rates of complications is difficult because there are
host factors that vary from case to case. However, based on experience if all medical
(i.e., pneumonia, UTI, bed sores, etc.) and orthopedic (aseptic loosening, infection,
dislocation, nerve injuries, etc.) complications are included. one can anticipate a
20–30% complication rate after a complex revision for a periprosthetic acetabular
fracture.
Table 3.3 Outcomes of surgical treatment of periprosthetic acetabular fractures
48
Early vs. late Number of Mean

Study identification fractures Classification Treatment plan follow-up Outcomes
Sharkey et al. Intraoperative 13 fractures Preop diagnosis = 6 6 = additional screw fixation Of the four found
[25] and early OA, 2 RA, 3 AVN, 1 1 = activity modification and postoperatively, all showed
postoperative hip fracture nonunion, TDWB-ing radiographic evidence of
1 developmental 2 = no modifications loosening, and two required
dysplasia 2 = required revisions revisions
Laflamme Intraoperative 32 patients 11 stable (type I), 12 Stable implants= No treatment failures in the
et al. [32] and early unstable (type II), Unstable implants = supplemental type I group
postoperative missed intraoperative fixation Non-union and fracture
(type III) displacement associated with
cases that did not undergo
posterior column plating
Type III had the highest
reoperation rate
Anterior column fractures
well tolerated, posterior
column fractures 67% failure
rate
Della Valle Intraoperative Non-displaced Non-operative treatment with or
et al. [20] fracture with stable without postoperative modifications
cup vs. unstable cup rehab restrictions vs. supplemental
fixation or fixation of fracture with
plating based on column stability
Zettl et al. [33] Early 8 patients Stable vs. unstable Minimally invasive technique to 1 year No revisions or soft-tissue
+ column defects conserve stable acetabular complications
components when anterior column
reconstruction is needed
T. A. Edmiston et al.
Early vs. late Number of Mean
Study identification fractures Classification Treatment plan follow-up Outcomes
Peterson and Late 11 patients 5 medial wall, 3 Non-operative treatment trialing for 62 months 80% required revision
Lewallen [6] posterior column, 2 stable implants mean
transverse, 1 anterior Acetabular component revision for follow-up
column unstable implants without
6 displaced by at least supplemental plate fixation
2 mm or more
Classified as Type
I = stable (8 patients),
Type II = unstable (3
patients)
Haidukewych Intraoperative 0.4% Stable vs. unstable Supplemental screw fixation for Elliptical monoblock cups
et al. [4] incidence, unstable highest rate: 3.5% vs. 0.09%
17/21 stable for hemispherical
Barlow et al. Late 63 patients Paprosky IIIb Custom triflange 4.32 months 13.5% failure rate
[26] classification Tends to lateralize hip center
Wind et al. Late 19 hips Paprosky IIIa/IIIb Triflange acetabular component 31 months 60–80% success rate
[29] Instability, nerve injury and
complications not
uncommon
Meneghini Late 8 patients All were Paprosky 3A Buttress augment 16.5 months No revisions, 1 iliac wing
et al. [28] or 3B bone loss fracture
classification
Brown et al. Late 31 patients All Type IIIa defects Figure 7 grafts 25 year 72% survivorship
[29]
Zazgyva et al. Late 28 patients, Paprosky Type II and Reinforcement ring and bone graft 4.8 year 85.2% survivorship at
[30] 29 hips III defects 10 years
Mao et al. [31] Late 26 hips Paprosky Type III Custom cages 67 months No revisions, no
3 Periprosthetic Fractures About the Acetabulum: Management of the Loose Component
defects radiographic migration of

the cup, 1 cup appears loose
49
Conclusion
Periprosthetic fractures of the acetabulum are a rare but potentially catastrophic

complication of THA. There is a vast range of presentation for periprosthetic frac-
tures of the acetabulum, from traumatic acute unstable fractures, to the chronic dis-
continuity. Management should be tailored to each individual patient, fracture
etiology, and skills/experience of the surgeon. Typically, non-displaced early frac-
tures can be treated non-operatively, with a stable acetabular component. When
operative intervention is required, it is typically complicated by bone loss from
acetabular reaming, osteolysis, and stress shielding. Solutions to such complex
cases often involve a variety of techniques and approaches. Column stability is cru-
cial to achieving adequate fixation of the acetabulum and reduces or prevents any
mobility at the bone/implant interface. Other basic goals are reduction of the frac-
ture in the acute setting and potential distraction in chronic, wear-related fractures.
Regardless of the construct used to manage periprosthetic fractures around a loose
acetabular component, it is important to remember these are difficult cases with
fairly high rates of complications, and despite improvement in patient reported out-
comes, they will likely not rival what we routinely see with primary THA.
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improved hip scores for revision THA with severe bone defects. Clin Orthop Relat Res.
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Chapter 4
Periprosthetic Fractures Around Total Hip
Arthroplasty with a Stable Component
Peter J. Shekailo, Erik N. Kubiak, Richard S. Yoon,

and Frank A. Liporace
Introduction
While total hip arthroplasty (THA) has provided an effective solution for treatment
of patients with arthritis of the hip since the mid-1960s, the surgical procedure has
presented a unique and difficult problem in the way of periprosthetic fractures
involving the femoral component [1, 2]. Periprosthetic femur fractures about THA
can be divided into two subcategories: intraoperative periprosthetic femur fractures
and postoperative periprosthetic femur fractures. These fractures can range from
minor injuries with a minimal effect on patient functionality to catastrophic injuries
requiring major reconstruction [3]. Proper management of these fractures depends
on stability of the implant, fracture location, fracture orientation, and the patient’s
overall bone stock [4]. While several different classification systems have been for-
mulated, the Vancouver classification system has been the most widely used to both
classify fractures and dictate management, as reviewed in Chap. 1. This classifica-
tion takes into account stem stability, the location of the fracture, and the quality of
the patient’s bone stock [5]. The classification is initially applied to postoperative
P. J. Shekailo
Division of Orthopedic Trauma and Adult Reconstruction, Department of Orthopedic
Surgery, Orlando Regional Medical Center, Orlando, FL, USA
E. N. Kubiak
Division of Orthopedic Trauma and Adult Reconstruction, Department of Orthopedic
Surgery, University of Nevada – Las Vegas, Las Vegas, NV, USA
R. S. Yoon · F. A. Liporace (*)
Division of Orthopedic Trauma and Adult Reconstruction,

https://doi.org/10.1007/978-3-319-43008-9_4
54 P. J. Shekailo et al.
periprosthetic femur fractures, but it has since been modified to include intraopera-
tive fractures as well [6].
This chapter will discuss the surgical management and techniques involving the
fixation of stable periprosthetic femur fractures of the greater trochanter and proxi-
mal femur. This group will include management of Vancouver A, Vancouver B1,
and Vancouver C-type fractures. The goal of the chapter is to provide the reader
with the surgical tools and techniques for management of these complex fractures
and discuss current controversies and pitfalls involving fixation and management.
Postoperative Vancouver Ag Fracture: Periprosthetic Fracture

About the Greater Trochanter
A 76-year-old female patient presents to the emergency department with right hip
pain after a mechanical fall at home. The patient had a right total hip arthroplasty
performed 20 years ago by an outside physician. She is able to bear weight but does
walk with an antalgic gait. The patient has tenderness to palpation over the greater
trochanter and has notable bruising. Prior to the injury, the patient had endorsed
groin pain when ambulating. The patient’s imaging is presented in Fig. 4.1. The
patient is diagnosed with a displaced fracture of the greater trochanter around her
right total hip arthroplasty.
Periprosthetic fractures of the greater trochanter are a relatively common compli-
cation following total hip arthroplasty. In a study by Hseih et al. (2005), the reported
incidence of greater trochanteric periprosthetic fractures was 2.6% out of 887 THAs
analyzed with a mean follow-up time of 11 years [7]. Generally, fractures of the
greater trochanter are considered stable due to the muscle balance provided by the
abductors and external rotators [3]. Fractures of the greater trochanter are generally
treated nonoperatively if the amount of displacement is less than 2.5 cm. A nonop-
erative treatment involves protected weight-bearing for 6–12 weeks with no active
abduction [8]. Surgery with open reduction and internal fixation is considered if the
displacement is greater than 2.5 cm or patient develops a painful nonunion with
Fig. 4.1 Anteroposterior and lateral radiographs of the right hip showing displaced, osteolytic
greater trochanter fracture about a total hip arthroplasty
4 Periprosthetic Fractures Around Total Hip Arthroplasty with a Stable Component 55
weak abduction strength and/or instability. Many periprosthetic greater trochanter

fractures are the result of osteolysis and particulate wear [9]. Fractures through
osteolytic lesions must be taken into account during the planning phase of manage-
ment as the acetabular liner and femoral head may need to be revised at the time of
surgery. A CT scan may be helpful in preoperative planning if a large osteolytic
lesion or if distal fracture propagation is suspected. Figure 4.2 presents a proposed
treatment algorithm for Vancouver Ag fractures.
Preoperative Planning
Prior to fixation of periprosthetic greater trochanter fractures, it is important that the

surgeon be prepared for the need for possible revision of the total hip arthroplasty.
As osteolysis is a major contributor to the etiology of these fractures, the source of
the osteolysis should be addressed at the time of surgery. Therefore, the previous
operative report should be available along with the appropriate implants available in
the room [10].
Positioning and Approach
The patient is brought to the operating room and placed in the lateral decubitus posi-
tion on a radiolucent table. This positioning allows for adequate exposure of the
greater trochanter as well as allows the surgeon to perform a revision of the THA
components if deemed necessary. Alternatively, the patient can be placed in the
supine position with a bump under the affected extremity if a revision is not being
considered. The surgical exposure is then performed using the distal portion of the
patient’s prior THA incision. The iliotibial (IT) band is then split in the orientation
of its fibers directly over the greater trochanter. If assessment of the hip prosthesis
is deemed necessary, an arthrotomy can be made to surgically dislocate the prosthe-
sis [10]. The authors’ preferred approach is the posterior approach to the hip as it is
extensile and can be used if the total hip arthroplasty needs to be revised in the
future [11].
Surgical Fixation
Open reduction and internal fixation of the greater trochanter is achieved through
the use of cerclage fixation or the use of a trochanteric claw plate and cable con-
struct. Cerclage fixation was historically performed with l6- or 18-gauge monofila-
ment wires and/or large gauge nonabsorbable suture in a 2- or 3-wire technique.
Common complications from suture and wire cerclage fixation were trochanteric
56
Vancouver Ag-type
periprosthetic femur Fracture
Minimally or non-displaced
Displaced (>2.5cm)
(<2.5cm)
Osteolysis absent Osteolysis Present Osteolysis absent Osteolysis present
1) Fixation of greater trocanter

with cerclage wires or trochanteric
Fixation of greater trocanter Protected weight-bearing,
claw/plate; +/-bone grafting
with cerclage wires or Protected weight bearing consider revision surgery to
2) Revise components to treat
trochanteric claw/plate address source of osteolysis
source of osteolysis
(e.g polyethylene exchange)
P. J. Shekailo et al.
Fig. 4.2 Proposed treatment algorithm for Vancouver Ag periprosthetic femur fractures
nonunions as well as high rates of wire breakage. Due to high rates of nonunion, the
use of multifilament cables and the cable grip system was popularized [12]. The
cable grip system was shown to be biomechanically stronger and lead to lower non-
union rates than the previously described techniques [13]. Trochanteric claw plates
were then developed to lower the cable wear rate and debris that may lead to accel-
erated wear of the bearing surface of the total hip arthroplasty [14]. This fixation
technique is generally preferred for displaced and/or comminuted fractures of the
greater trochanter.
After provisional reduction of the greater trochanter fracture, the cables are
passed around the proximal femur using a cable passer. The cable passer must be
maintained on the bone when encircling the proximal femur to not entrap the femo-
ral artery at this level. Care must be taken to avoid placing the cerclage cable on the
femoral component as this will lead to increased cable particulate debris. If possi-
ble, the cables should pass below the level of the lesser trochanter as this is more
biomechanically advantageous to resist the pull of the abductor musculature [12].
The trochanteric claw plate is then applied to the greater trochanter, and the cables
are tightened and secured using a crimping technique.
If osteolysis is present, the source of the osteolysis should be determined.
Typically, the osteolysis is a result of polyethylene wear of the acetabular component
[9]. In this instance, the acetabular liner should be revised to address the source of
osteolysis. Component positioning should be assessed as well to make sure the posi-
tioning of the acetabular component is not resulting in an accelerated particulate wear
rate. Bone allograft should be placed in the osteolytic cysts of the greater trochanter
to promote both unions of the fracture and to treat the osteolysis that is present [15].
Tips, Tricks, and Avoiding Pitfalls
• Multifilament cables and the use of trochanteric claw cable plates are biome-
chanically stronger and have reduced the rates of trochanteric fracture nonunions
and escapes.
• Cables should be passed below the level of the lesser trochanter if possible to
provide a more stable construct to oppose the pull of the abductor musculature.
• Care must be taken not to tighten the cables on the femoral component as this
will lead to particulate debris that could cause accelerated polyethylene wear.
• Revision implants should be made available if osteolysis of the greater trochanter
is suspected.
• The typical source of osteolysis is advanced polyethylene wear, and replace-
ment of the polyethylene should be performed in this scenario.
• Morselized bone graft should be used to fill in osteolytic lesions and aid in
fracture union.
• If the quality of the abductor musculature is under scrutiny, both dual mobility
and constrained acetabular liners could be made available to ensure stability of
the total hip arthroplasty.
Fig. 4.3 Low AP pelvis radiograph displays fixation of the osteolytic trochanteric fragment with
a trochanteric claw construct with cables. The acetabular component, polyethylene and femoral
head were exchanged due to the significant polyethylene wear that resulted in the osteolysis. The
femoral stem remained well-fixed
Conclusion of Case Presentation
Figure 4.3 shows the postoperative X-rays of the patient described in the case pre-
sentation. The osteolytic greater trochanteric fracture was fixed with a trochanteric
claw and cable device with good reduction. The surgeon performed an acetabular
component, polyethylene and femoral head exchange to address the polyethylene
wear as seen on the preoperative X-rays. The remaining osteolytic defects were
filled with cancellous chips. The patient was made protected weight-bearing in a hip
abduction brace with instructions for no active abduction.
ostoperative Vancouver B1 Fracture: Periprosthetic Fracture

P
at the Level of the Femoral Component with a Stable Implant
A 77-year-old male presents to the emergency department with left thigh unable to
bear weight after a fall from standing at home. The patient underwent a press-fit,
primary total hip arthroplasty 5 years ago by an outside orthopedic surgeon.
Imaging of the patient’s hip prosthesis and left femur was obtained and is shown in
Fig. 4.4. The patient was diagnosed with a fracture of the left femur at the level of
the femoral stem of his total hip arthroplasty. Based on the X-rays, there is no evi-
dence of disruption of the bone-implant interface and no subsidence of the femoral
component.
Fig. 4.4 AP and lateral radiographs showing a displaced Vancouver B1-type periprosthetic femur
fracture at and just below the level of the stem. There is no evidence of subsidence or gross loosen-
ing of the prosthesis
Periprosthetic fractures of the femur at the level of the stem (Vancouver B frac-
tures) account for roughly 80% of all cases of postoperative fractures around a total
hip arthroplasty [3]. These fractures all require surgical management except under
exceptional circumstances [16]. The main determinant of the management of these
fractures is the stability of the femoral component. Vancouver B1 fractures account
for the subtype of these fractures in which the femoral stem remains well-fixed.
These fractures are managed with open reduction and internal fixation. There are
several different techniques for fixation, and controversy remains as to the best
method of fixation of these fractures.
Preoperative planning is the most important phase of management for Vancouver

B-type periprosthetic femur fractures. As mentioned previously, the stability of the
femoral implant will dictate the correct management of the fracture. If the stem
remains well-fixed, the fracture can be treated with open reduction and internal fixa-
tion. If the stem is loose, the implant needs to be revised to a long-stemmed
diaphyseal-fit component that bypasses the fracture site. It is important to obtain
full-length anteroposterior and lateral femur radiographs to assess the bone-implant
interface along the entire femoral stem as well as look for any subsidence of the
implant (>10 mm) and/or varus tilt of stem [17]. Pre-injury films should also be
evaluated if available.
Despite careful scrutiny of preoperative images, roughly 20% of stems that

were concluded to be stable were found to be loose intraoperatively [18]. The
surgeon must be prepared for revision of the total hip arthroplasty for every
case involving a Vancouver B fracture if possible, the patient’s original opera-
tive note should be analyzed in order to obtain the make, model and sizes of the
implants originally placed. This includes a long-stemmed femoral component
that bypasses the fracture site. Prior data regarding high failure rates of open
reduction and internal fixation of periprosthetic femur fractures are widely
attributed to femoral components that were deemed stable but were actually
loose at the time of surgery [19].
Infection must also be excluded in the setting of a periprosthetic fracture. ESR
and CRP may be elevated in the setting of recent trauma. If there is suspicion of an
infectious process, a preoperative joint aspiration can be performed to evaluate
synovial white blood cell count and cultures [20].
The patient is brought to the operating room and placed in the lateral decubitus posi-
tion on a radiolucent table, such as a Jackson table. By placing the patient in this
position, the surgeon will be able to perform an extensile approach to the femur as
well as perform a hip arthrotomy to assess stability and perform a revision total hip
arthroplasty as necessary. A lateral sub-vastus approach or minimally invasive lat-
eral incision may be used depending on the desired fixation technique. A hip
arthrotomy can be performed using either the posterior or direct lateral approach
depending on the surgeon’s preference and expertise.
Alternatively, the surgeon may elect to place the patient in a supine position with
a bump or inflated beanbag under the operative leg.
There is current controversy as to whether all suspected Vancouver B1 frac-
tures should be assessed intraoperatively for femoral component stability with a
formal hip arthrotomy. The Swedish Hip Registry reported a 34% failure rate of
open reduction and internal fixation of Vancouver B1 fractures [19]. As stated
previously, many surgeons attribute this high failure rate to inaccurate assess-
ment of the femoral component stability. Some surgeons advocate performing
arthrotomies on all Vancouver B1 fractures to accurately assess femoral stem
stability [18]. This approach does result in a more invasive soft tissue dissection,
resulting in higher rates of nonunion as well as subjecting the patient to an
increased risk for postoperative dislocations [21]. The other opinion is to stress
the implant intraoperatively, either through the fracture at the distal portion of
the stem or with dynamic stressing of the stem under fluoroscopy [17]. The con-
sensus is that if there is any question of femoral component stability on radio-
graphs or intraoperative stressing, a formal hip arthrotomy should be performed
[17, 19, 20].
pen Reduction and Internal Fixation with Lateral Plating

O
with or Without Allograft Strut Application
Relative controversy in the literature exists regarding the optimal technique for fixa-
tion of Vancouver B1-type femoral fractures. This controversy surrounds the use of
isolated lateral locked plating versus the use of cable plating in combination with an
allograft strut. Biomechanical studies have shown that a lateral cable plate and
screws with anterior strut allograft placed in a 90-90 configuration offer the most
optimal fixation for these fractures [22]. Choi et al. [23] evaluated the biomechanics
of 90-90 plating as well, with this construct being more stiff than lateral plating and
allograft fixation. Despite the improved performance in the laboratory, the authors’
preferred method is to avoid allograft strut use due to the extensive soft tissue strip-
ping that is required during application of these grafts. Early literature had sug-
gested that locked lateral plating in isolation was not sufficient for fixation of these
fractures; however, modern improvements have done away with the weaker com-
parison. Buttaro et al. [24] reported that five or nine patients who underwent lateral
locked plating had failures of fixation postoperatively. Corten et al. [18] published
that union was achieved in 28 of 29 Vancouver B1 periprosthetic femoral fractures
that were treated with isolated lateral locking plates at that institution and allograft
struts were only used if the medial cortex of the femur could not be restored. The
authors’ preferred method is an isolated lateral locked plating system to reduce both
cost to the patient and soft tissue stripping that occurs around the fracture site.
Several surgical techniques and principles should be incorporated when planning
fixation of Vancouver B1 fractures. Proximal fixation generally requires >2.5 corti-
cal diameters of overlap to reduce failure rates [10]. Modern plates provide screw
and plate options that extend to the greater trochanter to provide sufficient overlap
of the plate and prosthesis [25]. As these fractures typically occur in patients with
osteopenic or osteoporotic bone, it is currently recommended to use a plate with
sufficient length to protect the entire length of the femur against future peri-implant
fractures [26]. Finally, care must be taken to not reduce the fracture with the stem in
a varus position, as this has a higher rate of fixation failure.
Operative Technique
After the fracture is exposed, the bone-implant interface should be examined for
any signs of loosening. If there is a concern, a formal hip arthrotomy should be
performed at this time if the surgeon had not already done so. Once implant sta-
bility is determined, the fracture is then reduced with reduction clamps, and a
plate is chosen to span the entire femur. The plate is provisionally fixed to the
bone with screws proximally and distally. If the fracture is transverse in nature,
compression can be obtained at this time by placing screws in compression mode
within the plate. Proximal fixation is then supplemented with hybrid fixation of
unicortical locking screws and cables. Hybrid fixation with screws and cables has
been shown to be biomechanically stronger than pure screw fixation [27]. Distally,
it has been proposed that fixation should be spaced with an approximate screw
density of 50% [28].
If a strut allograft is chosen, it should be prepared after the femoral implant is
determined to be stable. Acceptable strut allografts can be obtained from the distal
femur, humerus, or tibia with a minimum length of 25–30 cm [29]. A minimum of
two cables should be passed both proximally and distally to create a more stable
construct [16]. Generally, the cables should be passed prior to placing the allograft
onto the femur. Once the allograft is moved into position, the cables are then tight-
ened and crimped to hold the allograft in the correct position. Generally, a 90-90
construct is favored with the strut allograft fixed to the anterior cortex of the femur
[22]. A general tip is to avoid ending the strut allograft at the same level as the plate,
as this could lead to a stress riser at that level. Again, due to the required extent of
soft tissue dissection, the authors’ preferred method is as follows: utilization of a
locked lateral plate.
Minimally Invasive Isolated Lateral Locking Plate Fixation
The goal of indirect fracture reduction and a minimally invasive approach is to mini-
mize soft tissue damage and periosteal stripping to promote an environment ideal
for healing potential [30]. A direct lateral exposure of the proximal femur is per-
formed using the distal aspect of the previous total hip arthroplasty incision and is
extended just proximal to the fracture. Dissection is then carried down to the ilio-
tibial band, which is split in line with its fibers. A sub-vastus lateralis approach is
then utilized, and care must be taken to ligate or coagulate any large muscular per-
forating arteries. The vastus lateralis is retracted anteriorly. A second, separate inci-
sion is then made at the level of the metaphyseal flare of the distal femur. A cobb or
wood handle elevator is then used to create a submuscular, epiperiosteal plane to
allow for plate passage.
A lateral femoral locking plate is then passed epiperiosteally and fixed proxi-
mally two cerclage wires or cables by the technique described by Ricci et al.
[31]. The plate can also be fixed proximally with fracture reduction clamps.
Fracture reduction is then obtained by a combination of traction and the use of
the plate contour to aid in reduction. The plate is then provisionally fixed to the
femur distal to the fracture using either a nonlocking screw or threaded pin to
hold reduction and cause the plate to sit flush with the bone. The proximal por-
tion of the plate should then be fixed definitively with a combination of both
locking screws and cerclage cables. With current locking plate technology, the
polyaxial locking screws can bypass the prosthesis, or unicortical locking screws
can be placed as an alternative. Based on current literature, 2–4 locking screws
and 2–4 cerclage cable should be used in definitive fixation of the proximal seg-
ment of the plate [10]. The distal portion of the plate should be definitively fixed
with a combination of locking and nonlocking bicortical screws [32]. As with

standard locking technology, the locking screws should be placed after the non-
locking screws have been tightened fully [33].
The minimally invasive, indirect reduction technique has positive reported out-
comes. Ricci et al. [34] noted that 41 patients treated with this technique all had
fracture union at an average of 12 weeks and is associated with less morbidity than
the standard extensile approach. However, it is the authors’ low threshold to convert
or utilize the long, extensile approach for definitive open reduction and internal fixa-
tion if needed.
• It is critical to assess implant stability prior to surgical fixation. Preoperative

radiographs should be assessed for signs of femoral component loosening, such
as lucency around the bone-stem interface and signs of subsidence. Pre-injury
radiographs should be examined if available.
• Up to 20% of femoral implants deemed to be stable via radiographs were
found to be unstable upon formal intraoperative stressing [18]. Visualization
of the distal portion of the stem at the fracture site and/or dynamic fluoro-
scopic testing can be used to evaluate stability. If there are any doubts about
the stability of the stem, a formal hip joint arthrotomy and dislocation should
be performed to stress the femoral component.
• Revision implants, such as long-stemmed femoral components, should be
available in the operating rooms in case the implant is deemed unstable
intraoperatively.
• Fixation principles of Vancouver B1 periprosthetic fractures.
• Span the entire femur if possible to prevent the possibility of peri-implant
fractures secondary to the creation of stress risers.
• The proximal portion of the fixation should span the femoral component by
2.5 cortical diameters (typically up to the greater trochanter).
• Distal femoral fixation should use a combination of locking and nonlocking
screws depending on bone quality with approximately 50% spread of screws
(50% of screw holes distal to the fracture are filled).
• Avoid varus malposition of stem after reduction, which may lead to fixation
failure as well as aseptic loosening of the femoral component.
• Although early studies showed high failure rates with open reduction and inter-
nal fixation using isolated locked plate, current data has shown that it is compa-
rable in union rates to cable plating and strut allograft fixation.
• Minimally invasive plate osteosynthesis (MIPO) can be used to reduce mor-
bidity associated with large incisions and also maintains good blood flow at
the fracture site and has a low threshold to utilize the extensile lateral approach
as needed for direct visualization, reduction, and fixation.
• Although plating and allograft strut fixation in a 90-90 configuration is bio-
mechanically stronger than lateral locked plating, it requires significantly
more soft tissue and periosteal stripping. This has led to increased union times
and a higher infection risk in these patients; the authors avoid this method and
utilize lateral locked plating.
• Our preference is to utilize modern locked plating technology, as allograft
application requires significant soft tissue preparation as well as time to pre-
pare the graft. Increased open wound time increases risk of infection, which
can easily be harbored by allograft.
• If allograft strut fixation and cable plating is chosen, care must be avoided to not
end the allograft strut at the same level as the plate.
• The minimum length of the allograft strut should be greater than 25–30 cm.
Figure 4.5 shows the postoperative X-rays of the 76-year-old male who sustained a
left Vancouver B1-type periprosthetic femur fracture after a fall at home. The
patient’s fracture was addressed in the lateral position through a sub-vastus latera-
lis approach that converted to a posterior approach to the hip more proximally. The
implant stability was assessed intraoperatively and noted to be stable. Provisional
fixation of the fracture was obtained using multiple cerclage cables and clamps. A
distal femoral locking plate was then applied using locking screws distally and a
combination of cables and unicortical locking screws proximally. The patient was
made non-weight-bearing after the surgery.
Fig. 4.5 AP and lateral radiographs displaying ORIF of a stable Vancouver B1-type periprosthetic
femur fracture. Fixation was achieved with a distal femoral locking plate and a combination of
cerclage wires and unicortical screws proximally
ostoperative Vancouver C Fracture: Periprosthetic Fracture

P
Below the Level of the Femoral Component
Case Presentation
A 78-year-old female patient presents to the emergency room with left thigh pain
and deformity after a motor vehicle collision. The patient was unable to ambulate
on scene. She denies any other injuries. The patient had a cemented right total hip
arthroplasty 10 years ago. She denies any right thigh or groin pain prior to presen-
tation. Full-length anteroposterior and lateral femur films were obtained and are
shown in Fig. 4.6. The patient was diagnosed with a right femur fracture below the
level of her right total hip arthroplasty femoral component.
In postoperative Vancouver C-type fractures, the fracture occurs distal to the tip
of the femoral component. As the bone-implant interface is not disrupted by the
fracture, the femoral component is considered stable [35]. These fractures account
for approximately 10% of periprosthetic fractures around a total hip arthroplasty
[36]. Historically, these fractures were treated with prolonged bed rest with or with-
out traction. Due to the high rates on nonunion and the associated morbidity and
mortality associated with bed rest, these fractures are now treated typically with
open reduction and internal fixation with modern locked plating technology [37].
Mainly in Europe, retrograde intramedullary nailing of these fractures has been
performed in the low-demand, elderly population [38]. There are no adequate pro-
spective studies to analyze the outcomes of retrograde intramedullary nailing, and
there is a concern of creating an area of high stress between the nail and the femoral
component.
As with the previous fractures discussed, full-length anteroposterior and lateral

radiographs of the femur should be obtained prior to surgery. Although the implant
is generally considered stable when fractures occur below the tip of the femoral
prosthesis, the bone-implant interface should be examined closely to look for evi-
dence of loosening. While obtaining the history, care should be taken to note any
previous groin pain or start-up thigh pain to assess for potential issues with the total
hip prosthesis prior to the injury. If pre-injury films are available, they should be
examined and scrutinized as well. Revision implants should be made available as
necessary.
a b
c d
Fig. 4.6 AP and lateral radiographs of a Vancouver C-type periprosthetic femur fracture. The
fracture is below the stem but does extend to the cement mantle. There is no evidence of fracture
within the cement mantle or loosening of the femoral component itself, (a, c) are proximal and
distal radiographs of a left Vancouver C periprosthetic hip fracture. (b, d) are proximal and distal
radiographs of a Vancouver C periprosthetic hip fracture
Depending on the surgeon’s preference, the procedure may be performed in the

supine or lateral decubitus positon with a beanbag on a radiolucent table. A bump
should be placed under the injured extremity if the patient is placed in a supine posi-
tion. The C-arm should be positioned to shoot images from the contralateral side of
the patient if placed in the supine position.
A direct lateral approach to the femur or a minimally invasive two-incision
approach may be used for open reduction and fixation of the femur. The minimally
invasive approach is preferred if fracture reduction is possible due to minimal soft
tissue stripping and the ability to maintain blood supply at the level of the fracture
[31]. This approach uses a submuscular, epiperiosteal plane between the two inci-
sions to position the plate fixation both proximally and distally.
Surgical Fixation
Singular lateral plate fixation has been the mainstay of treatment for Vancouver
C-type fractures [17, 21, 39, 40]. Locking, nonlocking, and hybrid plating systems
exist currently that allow multiple options of fixation for these fractures. Fixation
principles are similar in nature to those of a Vancouver B1 fracture around a stable
implant [39, 40]. When possible, indirect reduction techniques with minimally inva-
sive approaches should be applied to preserve blood flow to the fracture site by
placing the plate in a submuscular, epiperiosteal plane.
Plate length is important in these fractures to avoid a stress riser between the
plate and the femoral stem. The plate should overlap the femoral component proxi-
mally by 2.5 cortical diameters [10]. As stated previously, the plate must be of suf-
ficient length to protect the entirety of the femur to avoid peri-implant fractures in
the future [26]. The plate is then fixed to the bone both proximally and distally. The
proximal portion of the plate can be fixated with cerclage cables or fracture reduc-
tion clamps. The distal portion of the plate should be fixed to the bone with a provi-
sional pin or nonlocking screw, using the plate as a reduction tool in the coronal
plane. Compression should be obtained at this time if the fracture pattern is ame-
nable (transverse, short oblique). Proximally, the preferred technique is to use
hybrid fixation using a combination of cables and locking screws in a polyaxial or
unicortical fashion. Based on biomechanical studies, cables are biomechanically
strong against bending loads but do not maintain as much torsional stability as uni-
cortical or polyaxial locking screws [41, 42]. Therefore, it is recommended to use a
combination of 2–4 locking screws and 2–4 cerclage cables for the proximal fixa-
tion of the plate. Distal fixation should be obtained with a combination of locking
and nonlocking screws with a 50% spread depending on bone stock. Although not
commonly used for these fractures, a cortical strut allograft may be used as supple-
mental fixation when bone stock is deemed inadequate or the medial cortex of the
femur is not adequately restored with fracture reduction [21]. Recent retrospective
reviews of lateral locked plating and hybrid fixation for Vancouver C periprosthetic
fractures have been promising, but further studies are needed to fully assess the suc-
cess of this treatment modality [37, 43].
Although Vancouver C-type periprosthetic fractures are considered to have stable

femoral implants, both injury and pre-injury films (if available) should be examined
for signs of loosening.
• A careful physical history should be obtained at the time of presentation to evalu-
ate for symptoms of total hip arthroplasty component failure (e.g., start-up thigh
pain, increasing groin pain).
• Fixation generally consists of isolated lateral locked plating or hybrid plate fixa-
tion. The fixation principles are similar to those mentioned in the section on
Vancouver B1 fractures.
• The entire femur should be protected to avoid the potential of peri-implant
fractures in this patient population, with overlap of the plate and femoral com-
ponent of approximately 2.5 cortical diameters.
• Cortical strut allografts can be used as augmentation in fractures with poor
bone stock or if the surgeon is unable to restore the medial cortex of the femur
(as stated above, the use of allograft is not authors’ preferred method).
• A minimally invasive approach and indirect reduction should be employed if
possible. This involves a two-incision approach with a skin and soft tissue bridge
over the fracture site. This allows for submuscular placement of the plate to
maintain blood flow at the fracture site.
• However, an extensile lateral approach should be utilized when a minimally
invasive approach cannot be utilized.
• Intramedullary nailing of Vancouver C fractures has been advocated in Europe.
This technique poses technical difficulties in terms of implant overlap and the
creation of a stress riser between intramedullary devices. More studies looking at
outcomes of this type of fracture fixation should be performed.
• This type of fracture fixation has been performed in the elderly, low-demand
population due to the potential for earlier mobilization and weight-bearing.
Figure 4.7 shows the X-rays of a 78-year-old female who sustained a left Vancouver
C-type periprosthetic femur fracture after a motor vehicle collision. It was elected
by the primary surgeon to proceed with fixation using a distal femoral locking plate.
Fig. 4.7 AP and lateral radiographs displaying fixation of the Vancouver C-type periprosthetic
femur fracture. The construct used a distal femoral locking plate with locking screws distally and
a combination of screws and wires proximally
The patient’s fracture was approached in the supine position with a bump and
utilized the sub-vastus lateralis approach. Provisional fixation was obtained with
clamps and cerclage wires. A distal femoral locking plate was then applied using
locking screws distally and a combination of cables and locking screws proximally.
The patient was made non-weight-bearing after the surgery.
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32. Bryant GK, Morshed S, Agel J, et al. Isolated locked compression plating for Vancouver type
B1 periprosthetic femoral fractures. Injury. 2009;40(11):1180–6.
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Trauma. 2004;18:488–93.
34. Ricci WM, Bolhofner BR, Loftus T, et al. Indirect reduction and plate fixation, without graft-
ing, for periprosthetic femoral shaft fractures about a stable intramedullary implant. J Bone
Joint Surg Am. 2005;87(10):2240–5.
35. Gaski GE, Scully SP. In brief: classifications in brief: Vancouver classification of postoperative
periprosthetic fractures. Clin Orthop Relat Res. 2011;469(5):1507–10.
36. Lindahl H, Garellick G, Regner H, et al. Three hundred and twenty-one periprosthetic femoral
fractures. J Bone Joint Surg Am. 2006;88(6):1215–22.
37. Currall V, Thomason K, Eastaugh-Waring S. The use of LISS femoral locking plates and
cables in the treatment of periprosthetic fractures around stable proximal femoral implants in
elderly patients. Hip Int. 2008;18:207–11.
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poor clinical outcome in the operative treatment of periprosthetic femoral fractures: an analy-
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plate osteosynthesis: fracture union and reoperations in 60 consecutive fractures. Acta Orthop.
2012;83(6):648–52.
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tures around well-fixed total hip arthroplasty. J Am Acad Orthop Surg. 2009;17(11):677–88.
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ture fixation techniques post total hip arthroplasty. J Biomech. 1992;25(5):469–76.
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43. Kobbe P, Klemm R, Reilmann H, et al. Less invasive stabilization system (LISS) for the treat-
ment of periprosthetic femoral fractures: a three year follow-up. Injury. 2008;39:472–9.
Chapter 5
Periprosthetic Femur Fractures
Around Total Hip Arthroplasty
with a Loose Component
Joshua Rozell and Derek J. Donegan
Although from a materials perspective total hip arthroplasty implants are becoming
stronger and more durable, periprosthetic fractures are on the rise. In one series of
over 30,000 THAs from a single institution, the prevalence of postoperative femo-
ral fractures was 1.1% for primary THA and 4.0% after revision THA [1]. Over the
next 10 years, the projected number of revision THA is expected to rise by over
130% [2]. On one hand, the number of people living with THAs has increased
dramatically [1, 3–6]. Patients are also more active and the demands placed upon
their primary prostheses are greater. Simultaneously, bone stock continues to
decline as one ages, creating a larger biomechanical mismatch between the metal
prosthesis and the surrounding bone. This, combined with the initial force required
to impact the stem and patient activity level, provides a formula for higher rates of
early and late periprosthetic fractures [1]. At the other end of the age spectrum,
younger more active patients are also undergoing THA procedures at a higher rate
for reasons such as early osteoarthritis, traumatic arthritis, or avascular necrosis
[4]. These patients are more at risk for fracture as a result of exposure to higher-
energy trauma and the development of local osteolysis. Minimally invasive tech-
niques and the use of newer implants may also play a role in the rising number of
periprosthetic fractures [3].
While the absolute number of periprosthetic fractures is expected to increase, [5]
the true incidence of this complication is largely unknown due to the heterogeneity
of the population reported in the literature [4]. Fractures that occur years after the
index procedure are commonly associated with late prosthetic loosening and signifi-
cant osteolysis [7]. Bethea et al. reported that over 75% of all postoperative fractures
are related to loose implants [8]. Similarly, Duncan et al. reported 82% of type B
fractures occurred in the presence of loose implants [9]. Stress risers contributing to
J. Rozell (*) ∙ D. J. Donegan

Department of Orthopedic Surgery, Hospital of the University of Pennsylvania,
Philadelphia, PA, USA
e-mail: Joshua.Rozell@uphs.upenn.edu

https://doi.org/10.1007/978-3-319-43008-9_5
74 J. Rozell and D. J. Donegan
fracture can be in the form of screw holes, missed perforations as a result of iatro-
genic fracture or secondary to component migration, eccentric reaming and cortical
lysis, and bony erosions [7].
The burden of periprosthetic hip fractures is significant. New Zealand registry
data showed that 6-month mortality after revision THA associated with a peripros-
thetic fracture (7.8%) was higher than in a matched cohort of patients undergoing
revision THA for aseptic loosening (0.9%). At the 1-year mark, Carli et al. found an
11% increase in overall mortality risk, a rate approaching the general hip fracture
population [10, 11]. Others have found similar rates of mortality at 1 year [5, 10].
Postoperative rehabilitation protocols and mobilization may help mitigate this risk to
some extent.
Patient Evaluation
Risk Factors
Several factors place patients at higher risk for periprosthetic fractures following
THA. These include osteoporosis, inflammatory arthritis, female gender, presence
of large osteolytic lesions or stem loosening, advanced age, and a history of devel-
opmental hip dysplasia [5, 11–14]. In addition, other variables such as proximal
femoral geometry, cortical thickness, and surgical technique may influence fracture
risk [11]. Regarding gender, data are conflicting. Cook et al. found that patients over
70 years of age had a 2.9 times greater risk of sustaining a periprosthetic fracture but
found no association between fracture and gender [15]. Similarly, Abdel et al. evalu-
ated the Mayo Clinic Joint Registry from 1969–2011. Postoperative fractures were
more common in men less than 70 years old. Other studies have identified female
gender as a specific risk factor [11, 16, 17].
Biomechanical studies have demonstrated that loose femoral stems have a nearly
60% reduction in the torque to failure compared with well-fixed stems [18]. The
Swedish registry showed that for primary THA 70% of fractures involved loose
prostheses, 23% of which were known to be loose and 47% first identified as loose
at the time of surgery [19]. For the revision group, 56% were known to be loose, and
21% were found to be loose intraoperatively. In a study by Beals and Tower, 27% of
patients with fractures had evidence of loosening preoperatively [20].
The use of uncemented stems may be related to the risk of periprosthetic frac-
ture. Especially in osteoporotic patients, the force imparted with impaction of the
stem may increase the femoral hoop stresses enough to cause small cortical frac-
tures unrecognized intraoperatively. Thien et al. reported on almost half a million
THAs from the Nordic registry over a 15-year period. In the registry, the use of
cementless stems was associated with over five times the incidence of peripros-
thetic fracture (0.45% vs 0.08%). They concluded from this comparison that
cementless stems should be avoided when advanced age, female gender, and a
5 Periprosthetic Femur Fractures Around Total Hip Arthroplasty with a Loose… 75
f emoral neck fracture are present. They also identified differences among specific
cementless and cemented stem designs [21]. In Abdel et al.’s review of the Mayo
Registry, there was no difference in fracture risk for cemented and uncemented
stems. However, fractures occurred earlier after uncemented revision of the femoral
component and later after a cemented revision. After revision THA, the cumulative
probability of a postoperative periprosthetic femoral fracture was 1.9% at 1 year,
3.8% at 5 years, 6.4% at 10 years, and 11.4% at 20 years. Of the 281 postoperative
fractures, 135 occurred after 2781 uncemented femoral revision THAs and 146
after 2636 cemented femoral revision THAs. The risk of fracture did not differ
significantly between cemented and uncemented femoral stems. The 20-year cumu-
lative probability of fracture for a cemented stem was 10.2% and 12.1% for an
uncemented stem. Fracture within the first year was statistically more likely with an
uncemented stem than with a cemented stem [22].
Patient Evaluation
Patients who sustain periprosthetic femoral fractures usually present to the emer-
gency department after low-energy trauma. Higher-energy trauma from motor vehi-
cle accidents or falls from a height are also possible, and these patients are often
evaluated in the trauma bay. A thorough history and physical exam may reveal a
history of groin or thigh pain prior to the injury that may be an indication of implant
loosening. Patients who sustain ground-level falls, especially the elderly, should be
evaluated by a medical team for syncope and neurologic or cardiac disease. On
physical examination, one may observe a leg length discrepancy, a rotational defor-
mity to the affected leg, or thigh swelling associated with femoral canal bleeding
and soft tissue injury. Patients will also have limited range of motion, an inability to
bear weight, and pain with log roll of the leg.
The contribution of infection to periprosthetic fracture is unclear. Further, the
inflammatory markers erythrocyte sedimentation rate (ESR) and C-reactive pro-
tein (CRP) have poor specificity in the setting of a fracture [23, 24]. In one study,
Chevillotte et al. evaluated 204 patients. Lab values were compared with subse-
quent hip aspiration and a true infection was diagnosed in 11.6% of patients. White
blood cell count was increased in 16.2% of patients, ESR was increased in 33.3%,
and C-reactive protein increased in 50.5%. However, the positive predictive value
was poor (<30%) [25]. If aspiration is attempted, the white blood cell (WBC)
count should be adjusted based on the red blood cell (RBC) count which will be
elevated in the setting of fracture (WBC adjusted = WBC observed – [(WBC blood
x RBC fluid/RBC blood)] [23]. If there is a high clinical suspicion for infection,
cultures and tissue samples should be obtained intraoperatively and sent for frozen
section. At the time of second-stage reimplantation surgery, frozen section is use-
ful in ruling in infection with specificity greater than 90%; however, there is less
utility in ruling out infection, because sensitivity is approximately 50% [26, 27].
Radiographic Evaluation
In patients with suspected fracture, standard anteroposterior and cross-table lateral

radiographs should be obtained to assess for fracture morphology, implant stability,
component malposition, bone stock, the location of any osteolytic lesions, and the
presence of wear [13]. If prior radiographs are available, they are useful in subtle
fracture assessment. For example, evaluating the height of the femoral prosthesis
may show evidence of subsidence that would indicate fracture and/or loosening.
The femoral component is considered osseointegrated if there is increased bone
density adjacent to the implant porous coating and if divergent radiolucent lines,
implant subsidence, and pedestal formation were absent [28, 29]. In some cases, a
computed tomography (CT) scan may be used as an adjunct for assessing fracture
characteristics including fracture propagation around the stem, areas of bony spot-
welding, regions of bone loss, and the position of the components [13].
Fracture Classification
The Vancouver classification is primarily used to describe periprosthetic hip frac-

tures. The site of the fracture (Fig. 5.1a), the stability of the prosthesis, and the
integrity of the bone stock (Fig. 5.1b) serve as the three most important parameters
in guiding surgical decision-making [30]. Furthermore, this system has been shown
to be both reliable and valid [31, 32]. Of particular importance is distinguishing
between a B1 and B2 fracture. Historically, open reduction and internal fixation of
fractures with a loose femoral prosthesis have had poor outcomes (Fig. 5.2) [20].
According to data obtained from the Swedish Registry, there was a high frequency
of repeat surgery after treatment of B2 fractures with open reduction and internal
fixation alone (30%) [19]. For B3 fractures fixed with compression plating, Haidar
et al. found a 100% failure rate leading to reoperation [33]. Recognition of a loose
prosthesis may be difficult on preoperative radiographs (Fig. 5.3). Corten et al.
reported a 20% rate of misclassification on preoperative radiographs leading to a
change in management [34]. Lindahl et al. reported that the failure rate is probably
due to an under diagnosis of loose implants resulting in inadequate treatment. The
authors concluded that classifying a periprosthetic femoral fracture in the Vancouver
B category is difficult and inconsistent, and the prosthesis should be considered
loose until proven otherwise [35]. Surgical exploration of the joint is therefore rec-
ommended for all patients with a Vancouver B fracture pattern assessed radiograph-
ically. If there is doubt regarding the fixation status of the stem, revision of the
femoral implant and open reduction and internal fixation of the fracture are recom-
mended [35].
b
Loose?
No Yes
B1 Bone
Stock?
Good Poor
B2 B3
Fig. 5.1 Anteroposterior radiograph of the femur (a) with a total hip replacement in place,
depicting the zones of fracture according to the Vancouver classification. The A-type fracture
occurs around the greater or lesser trochanter (AG or AL); the B-type fracture occurs in the region
of the stem and is subclassified based on stem stability and integrity of bone stock; type C frac-
tures occur distal to the stem. The B-type fractures are further classified based on stem stability
and bone stock (b)
a b
Fig. 5.2 Immediate postoperative (a) and 5-week postoperative (b) anteroposterior radiograph of
the left hip showing failure of fixation for a periprosthetic fracture around a loose stem treated only
with open reduction internal fixation
Fig. 5.3 Preoperative
anteroposterior radiograph of a
76-year-old male who sustained a
ground-level fall and presented to
the emergency room with hip pain.
The radiograph illustrates the
difficulty in determining stem
stability based on a radiograph at a
single time point
a b
Fig. 5.4 Preoperative anteroposterior hip (a) and anteroposterior pelvis (b) radiographs of a
patient who sustained a B-type periprosthetic fracture around a loose stem. Images are placed
within the preoperative plan for reference
Operative Management
Operative Goals
The goals of treatment in periprosthetic femoral fractures are to provide fracture

union, anatomic alignment, return of functional status, early mobilization, achieve-
ment of a stable prosthesis after fracture healing, and a reasonable survivorship of
the prosthesis [36–38]. In the elderly population, the fixation construct should out-
live the patient [39], and bone stock should be preserved to the greatest extent
possible [12].
The success of any complex case begins with a thorough preoperative plan. The
operative record should be obtained from the patient’s index surgery to understand
the surgical approach and implants utilized. Implant labels may also be obtained
from the operative record if the operative report is not immediately available or does
not list the specific implants used. One should always be prepared to revise the
acetabular component in the case of malposition or loosening. A preoperative equip-
ment list should be provided to the operating room staff to ensure that all items and
implants are made available for the case (Table 5.1). A detailed surgical plan
(Table 5.2) provides a clear framework for the procedure.
Intraoperative Tips and Tricks
Once the fracture site is exposed and debrided adequately, evaluation of the fracture
pattern and stem stability will dictate the subsequent steps. For fractures with little
comminution and well-defined fragments, reduction may be performed first and the
stem implanted subsequently. This will optimize bony contact and compression.
Commonly, however, the fracture site serves as an extended trochanteric osteotomy
(ETO) that will later facilitate component implantation and can be readily reduced
around the prosthesis following insertion. This technique is especially useful in
patients with proximal femoral varus remodeling and retroversion [37]. In a study
by Levine et al. with 14 patients and 2-year follow-up, there was healing of both the
fracture and the ETO, and all of the femoral components were osseointegrated [37].
In Mulay’s technique, the fracture itself is propagated proximally using a vertical
trochanteric osteotomy through the junction of the anterior and the middle thirds of
the greater trochanter. This allows direct exposure of the prosthesis without any dis-
section of the soft tissues from the bone, thus preserving the blood supply of the
fracture fragments. The prosthesis is then removed along with cement remnants and
biomembrane [38].
Table 5.1 Detailed Patient position: lateral decubitus, axillary roll

preoperative equipment list
Table: radiolucent Jackson table
Positioners: Stulberg hip positioners (single pad posteriorly,
double pad anteriorly)
C-arm
Bovie: 50/50
Cell saver
Retractors/special equipment:
Self-retainer x2
Adson-Beckman Retractor x2
Hibbs x2
Cobb elevator
Charnley retractor (shallow and deep blades)
Acetabular retractors
Double-footed proximal femoral retractor x2
Flexible osteotomes
High-speed burr (pencil tip)
Pointed reduction clamps (small, medium, and large)
Culture swabs/specimen containers
Femoral canal reamers
Implants:
SL revision stem (i.e., diaphyseal fitting)
Cluster vs multi-hole acetabular shell
Elevated lip acetabular liners
Distal femoral variable angle locking plate
Dall-Miles cables (including tensioners and small/large passers)
Table 5.2 Preoperative surgical plan

Patient name: XXX Diagnosis: R periprosthetic femur fracture
Age: XX Date of surgery: XX
Past medical history: XX Post-op anticoagulation: Lovenox x6 weeks
Past surgical history: XX Procedure: R conversion THA (from hemiarthroplasty),
possible ORIF
Allergies: XX Implants: SL revision stem, distal femur variable angle
locking plate, cables, cluster vs multi-hole acetabular shell
Medications: XX Post-op pain management: Oxycodone 5–10 mg q4–6 h,
OxyContin 10 mg BID, Neurontin 300 mg BID, Diazepam
5 mg q6 h PRN
Imaging: See Fig. 5.4a, b
Hgb: x K+ Cr: x BMI: xx Albumin: INR: xx
xx
ESR: xx CRP: xx
Verify: Cross-match for 4u PRBC, preoperative antibiotic administration, tranexamic acid
administration
Confirm: current implants – acetabulum/femur/head size
Physical examination/neurovascular status/note prior incisions
Table 5.2 (continued)
Detailed preoperative surgical technique
Positioning:
Transfer patient to table with OR table bedsheet under lumbar spine, leave sheets/blankets on
stretcher
Remove traction pin if placed prior to surgery
Position patient in the lateral decubitus position with the right side up and apply hip
positioners
Single pad over the sacrum
Double pad over the ASIS and pubic symphysis, beginning slightly proximal and angling
distally
Place egg crate under down leg; apply axillary roll 2 fingerbreadths beneath left axilla
Secure right arm over elevated arm board or pillows
Tape down leg to bed at the ankle
Assure hip positioners are in good position and will allow hip flexion to 90 degrees
Pelvis should be level to floor and stable
Draping:
Non-sterile blue U drape around the groin and 10–10 drape across the upper pelvis
Hang leg in candy cane
Non-sterile scrub with betadine scrub brush
Sterile paint with betadine stick
Down sheet
2 sterile towels stapled together and placed around groin and stapled to skin; 1 sterile towel
across upper pelvis
Impervious blue U sheet from bottom over towels
Impervious blue U from top over towels
Impervious stockinette over the foot to the level of Gerdy’s tubercle
Mark out old incision and discard marking pen
Ioban along bottom of leg
Ioban top of leg
Sticky U drape up
Bar drape across pelvis
Surgical approach: extensile posterolateral approach to the hip/femur
Evaluate old incision; if in adequate position, use and extend
If malpositioned, draw new incision
Clearly identify fascia; use cobb elevator to clear off
Fascial incision based over vastus ridge then complete with mayo scissors
Define plane between underlying gluteus maximus and deep gluteus medius
Split gluteus maximus and place Charnley retractor beneath fascia
Identify posterior border of vastus lateralis
Identify gluteus maximus insertion on posterior border of femur and release (careful due
close proximity sciatic nerve)
Follow posterior border of vastus lateralis proximally into posterior capsular approach
Extend the approach proximally over the border of the acetabulum and posterior ilium
Tag posterior capsule with 3-#5 Ethibond sutures
(continued)
Posterior structures might be disrupted due to fracture; if so, follow to acetabulum
Follow vastus lateralis distally and approach femur via subvastus approach to expose fracture
Identify and coagulate/tie off perforators
Carefully free remainder of femoral prosthesis from greater trochanter using flexible
osteotomes and high-speed burr if necessary
Dislocate and remove prosthesis using a bone hook
Acetabular preparation (if needed)
Place retractor over anterior acetabular wall (poke through capsule with tonsil and spread to
create trajectory)
Place retractor over posterior acetabular wall or under transverse acetabular ligament
Once fully exposed, examine prior acetabular shell for stability
If loose or malpositioned, remove liner and screws if present and use explant osteotomes to
remove cup
Using prior head size as a template, begin reaming 2 mm below that
Initially medialize, then sequentially ream up with correct version and abduction angle to
achieve an adequate rim fit (between anterosuperior/posteroinferior columns)
Once satisfied, impact acetabular component
Secure acetabular component with 2 screws into the posterosuperior quadrant
Insert polyethylene liner and impact
Femoral preparation
Expose proximal femur and shaft
Using the Charnley, retract the greater trochanter fragment anteriorly
Place prophylactic cable distal to fracture site prior to reaming (roughly 1 fingerbreadth or
1 cm distal to the distal extent of the fracture line)
Begin reaming by hand
Ream until engaging diaphyseal fit is achieved
Insert trial stem, attach modular neck/head, and reduce the hip to assess length and stability
If the fracture fragments “line up” with the hip reduced, then the length is approximated
Check reduction/length with fluoroscopy
Place femoral stem
Place trial body with standard neck and + 0 head
Assess stability
If stability acceptable, mark version with Bovie on the femur
Remove trial body and place real components
Reduce hip
Use high-speed burr to burr out the inner aspect of the greater troch piece (if needed due to
excessive varus remodeling)
Reduce greater trochanter fragment back to femur using pointed reduction clamps and then
secure with 2–3 more cables below the level of the lesser trochanter
Closure
Irrigation with 3 liters of warm normal saline
Allow vastus lateralis to drape over femoral shaft
Repair posterior capsule using free needle and previously placed heavy suture
Place subfascial drain, exiting proximally, anterolaterally
1 vicryl interrupted suture for fascia
2–0 vicryl deep dermal suture
3–0 nylon vertical mattress for skin (if prior incision used); if new incision used, may close
with staples
Assess need for incisional vacuum dressing based on edema/drainage; if necessary, place
vacuum sponge over nonadherent dressing on skin; leave in place for 3–5 days at 80 mmHg
Postoperative plan
Toe-touch weight-bearing (10–20 pounds)
Posterior hip precautions; no active abduction for 6 weeks; abduction pillow
Remove drain when <20 cc/shift
Deep venous thrombosis prophylaxis for 6 weeks
Antibiotics pending culture results
Follow-up cultures
Physical therapy/occupational therapy
Abbreviations: THA total hip replacement, ORIF open reduction internal fixation, BID twice daily,
PRN as needed, Hgb hemoglobin, K potassium, Cr creatinine, BMI body mass index, INR
International normalized ratio, ESR erythrocyte sedimentation rate, CRP C-reactive protein, PRBC
packed red blood cells
After locating the distal extent of the fracture, a cable should be passed roughly
1.5 cm or 1 fingerbreadth below the fracture around the femoral shaft and secured
(Fig. 5.5). This serves two purposes: first, placement of a prophylactic cerclage
cable will prevent propagation of the fracture line as the new stem is potted. In addi-
tion, the cable can also later serve as a radiographic marker to assess prosthesis
migration [37, 38, 40]. The femoral canal is first reamed by hand and then on power
until adequate distal fixation, approximately 4–6 cm, can be obtained with the revi-
sion femoral component. The femur is typically underreamed by 0.5 cm compared
to the diameter of the revision femoral component. For a fully porous-coated,
diaphyseal-fitting stem, 4–6 cm of cortical bone is required for adequate distal fixa-
tion and an acceptable rate of bony integration [37]. If the implant does not advance
during later impaction, the implant should be disimpacted, and further preparation
of the canal should be undertaken to allow the stem to bypass the appropriate area
[41]. Once the stem is potted and prior to definitive fracture reduction, a modular
proximal body/neck component trial is added to assess stability once the hip is
reduced. Dialing in the appropriate anteversion of the modular proximal body and
neck component is critical. To assess rotation, several landmarks can be used: the
linea aspera may be disrupted by the fracture, but if once the fracture is provision-
ally reduced around the stem, the linea is readily visible this can be used as a marker
for the posterior aspect of the femur; the epicondylar axis of the knee is also a useful
landmark for which anteversion of the component may be judged. As a general rule,
if the fracture fragments are reasonably aligned when the hip is reduced, this may
serve as a checkrein for appropriate soft tissue tensioning and offset.
Once the implant is potted distally, the fracture fragment or ETO can be reduced
back onto the prosthesis. Care should be taken to preserve any soft tissue attach-
ments remaining on the fragments as maintenance of vascularity will aid in osteo-
genic potential [42]. The reduction is held with small and medium pointed reduction
clamps (Fig. 5.6), and cables are passed around the femoral shaft and tensioned to
a b
Fig. 5.5 Intraoperative photograph (a) following exposure and stem trialing. A prophylactic cable
was placed distal to the fracture site to prevent propagation of the fracture line during reaming and
impaction of the trial. The cable serves to dissipate hoop stresses. Adequate exposure of the entire
fracture is critical to ensure appropriate placement of the cable. Postoperative anteroposterior
radiograph (b) of the distal femoral shaft highlighting placement of the most distal cable
Fig. 5.6 Intraoperative photograph showing reduction of the fracture fragments around the long
implant. One should always begin reduction using the smallest pointed reduction clamps possible.
Using clamps that have a spin-down locking mechanism is useful for fine control of compression
and also for adjustments. (Courtesy of Dr. Neil Sheth)
secure the lateral fragment to the device anatomically. Multiple cables should be
applied to ensure adequate stability. Following fixation, the neck (if modular) and
trial head are applied to the prosthesis. The femoral head is reduced into the acetab-
ulum, and again the hip is brought through several positions to confirm stability.
These positions include extension and external rotation, a position of sleep, and
flexion/internal rotation. Leg length should also be assessed. Adjustments can then
be made to allow for increased or decreased offset as well as increased or decreased
leg length. Once the appropriate stability is achieved, the final implants are impacted
onto the stem. The hip capsule and or external rotators are repaired to increase the
stability of the hip and decrease potential for dislocation. The fascia and skin are
closed in a standard fashion. If there is concern for wound complication an inci-
sional vacuum dressing may be applied for 3–5 days to decreased tension on the
skin and improve healing potential [43]. The patient is made touch-down weight-
bearing (10%) with the use of a walker. Physical therapy is started on postoperative
day number one. If there is concern for dislocation or abductor insufficiency, an
abduction brace may be applied for 6 weeks.
Supplemental Plate Fixation
For B2 and B3 fractures once the implant is revised, the fracture is essentially con-
verted to a B1 pattern. In this way, supplemental locking plates may be added to
augment stability, prevent implant subsidence, and protect the remaining femur
from stress risers and potential fracture by distributing the load sharing across the
entire bone. Several studies have evaluated the use of plating in periprosthetic frac-
tures [34, 44, 45]. When this technique is undertaken, several key points are crucial
for success. First, one must choose a plate that ideally allows for screws to be passed
anterior and posterior to the stem. This ensures that at least some screws will be
bicortical which improves the stability of the construct [46]. In this regard, fluoros-
copy should be used in the operating room to assess plate balance prior to fixation.
Depending on screw hole position, the plate may sit slightly more anterior or poste-
rior than directly lateral. Once adequate plate balance is achieved, the plate should
be fixed using a practical algorithm “pin, pin—lag, lag—lock, lock.” The plate is
first provisionally pinned to the proximal femur using a 2.0 mm Kirschner wire. The
rotation of the plate is then confirmed fluoroscopically before pinning the plate dis-
tally. Once provisionally secured, non-locking screws should be inserted proximally
and distally in the plate to lag the bone. Keeping the plate as close to bone as pos-
sible before locking the construct will provide the most stability, as the plate will be
closest to the center of rotation of the femoral shaft. Once lagged to the bone, a
hybrid fixation construct of locking and non-locking screws should be inserted
along the length of the plate. Screw spread should allow for 10 cortices of fixation
over the entire length of the plate with attempts to make most screws bicortical [45].
Using sharp drill bits and the oscillate function on the drill can assist in passing the
drill bit across the limited amount of cortical bone around the prosthesis. In areas
where screw purchase is limited, supplemental cables can be passed around the
plate and the femur to hold the construct together at that location. However, cables
should be used sparingly and only if absolutely required (Fig. 5.7).
Implant Selection
Historically, periprosthetic femoral fractures around a loose stem were treated with
diaphyseal-fitting long-stemmed prostheses. As implant characteristics have
improved, many surgeons are now using modular devices to finely adjust antever-
sion [13]. However, there is still debate regarding the most appropriate treatment
algorithm [36].
Extensively porous-coated monoblock stems are a reliable implant for B2 frac-
tures (Fig. 5.8). These implants are designed to bypass the fracture site by 4–6 cm.
Springer et al. suggest that fractures treated with these stems had greater survival
rates, stable fixation, and lower rates of nonunion than over types of stems [47]. At
a b c
Fig. 5.7 A 91-year-old female presented to the emergency department after a fall, twisting her
right leg. She had immediate pain and inability to bear weight. Anteroposterior radiograph (a)
showing a spiral oblique periprosthetic fracture around a metaphyseal-fitting primary stem.
Anteroposterior radiographs (b and c) of the femur demonstrating long-stem diaphyseal fixation
with a supplemental lateral femoral locking plate used to distribute forces across the entire femur
to prevent stress risers and interprosthetic fracture. Fixation of the plate to the bone is achieved
with a hybrid construct of screws and cables. Locking screws are placed through the cement man-
tle of the total knee prosthesis. A screw is also used just distal to the hip prosthesis, acting as a
pedestal to prevent subsidence
a b
Fig. 5.8 Preoperative anteroposterior radiograph (a) of the left hip in a 72-year-old female show-
ing a B2 periprosthetic fracture. The total hip replacement was initially performed with a
metaphyseal-fitting, flat-wedge tapered stem. Postoperative radiograph (b) demonstrating revision
fixation using a collared, fully porous-coated monoblock stem. In this case, the distal cable was
placed prophylactically prior to implantation of the stem. The second, proximal, cable was used to
capture the lesser trochanter fragment. (Courtesy of Neil Sheth, MD)
2–9 years of follow-up, Weber et al. found that in 39 patients using the Wagner
stem, two stems became loose. All others remained stable up to 9 years. The advan-
tage of the Wagner stem is design simplicity, diaphyseal anchoring, and rotational
stability. The only area for potential breakdown is the head neck junction [48].
Introduced in 1987, subsidence rates of the Wagner stem in up to 50% of cases that
is less than 10 mm may be clinically insignificant [49]. O’Shea et al. performed a
retrospective clinical and radiographic assessment of 22 patients with mean follow-
up of 33.7 months, 10 of whom sustained a B2 fracture, and 12 of whom sustained
a B3 fracture. They used uncemented extensively coated stems for revision arthro-
plasty and reported a 91% union rate and 18 excellent outcomes [28]. Favorable
results were also appreciated by Garcia-Rey et al. They reported on 35 patients with
20 B2 and 15 B3 fractures revised with extensively coated monoblock stems. All

hips showed radiographic ingrowth fixation and all fractures healed. While 19 hips
showed signs of implant subsidence, this was not clinically or functionally limiting
[42]. These stems do have complications, however. Sheth et al. reported on 21 B2
and B3 fractures, finding a 33% risk of complication including instability, subsid-
ence, infection, heterotopic ossification, and osteotomy nonunion [29].
While much clinical success has been achieved with the extensively porous-
coated stems, modular revision stems have become more popular in recent years
because multiple goals of the revision operation may be achieved independently
(Figs. 5.9 and 5.10). Firstly, the distal stem component enables the solid fixation of
the prosthesis in the isthmus of the femur while bypassing the fracture. While doing
so, the proximal portion of the stem can be used to adjust anteversion, offset, and
length of the stem to maximize stability [50]. Abdel et al. evaluated 44 consecutive
patients with B2 (25) or B3 (19) fractures treated with fluted, tapered stems. At an
average follow-up of 4.5 years, they reported 98% radiographic healing rate, and
while they did use cortical strut allografts in eight cases, many patients reconstituted
their proximal femoral bone stock without the need for grafting. The mean Harris
Hip Score was 83 at most recent follow-up [51]. In other studies employing similar
stems, Park et al. and Mulay et al. found an over 91% union rate [38, 52]. Mulay’s
group found an average subsidence of the femoral stem of 5 mm in the first 6 months.
To limit subsidence, some have described distal interlocking screws through the
stem. Fink et al. reported nine successfully treated Vancouver types B2 and B3 frac-
tures with a distally fixed modular cementless revision stem. In cases where the
a b c
Fig. 5.9 A 67-year-old man presents to the trauma bay 1 week after a primary total hip replace-
ment. He is unable to bear weight and has had continued pain. No recent trauma. Anteroposterior
(a) and cross-table lateral (b) radiographs show that the femoral stem is positioned laterally and
posteriorly outside of the femoral canal. Intraoperatively, a ball-tipped guided wire may be used
and confirmed with fluoroscopy to ensure the wire is within the femoral canal. Postoperative
anteroposterior radiograph (c) showing a modular, diaphyseal-fitting stem
a b c
Fig. 5.10 A 95-year-old female was found down in her home and brought to the emergency depart-
ment. Her right leg was shortened. Anteroposterior radiograph (a) showing a periprosthetic femur
fracture with likely loose stem. Anteroposterior (b) and lateral (c) radiographs taken postopera-
tively demonstrating a modular, diaphyseal-fitting prosthesis with multiple cables used for supple-
mental fixation and fracture reduction. Given the comminution proximally and calcar fracture, the
ability to control anteversion is helpful for establishing maximum stability of the prosthesis
femoral isthmus was disturbed by the fracture or fixation length was less than 3 cm,
additional interlocking screws were used for fixation. In this way, there was no sub-
sidence over 5 mm or stem loosening in a follow-up of at least 2 years [53]. Similarly,
Mertle et al. retrospectively reviewed 725 revision THAs using interlocking stems
from 14 French orthopedic departments. Indications included 150 periprosthetic
fractures. The majority of these fractures (70%) were Vancouver B2 or B3. Seven
different distal locked stems were used: 205 straight modular stems with partial
hydroxyapatite (HA) coating, 405 curved modular stems with partial HA coating,
and 115 curved modular stems with total HA coating. Average follow-up was
4.5 years. In cases of periprosthetic fractures, union was obtained in 95% of cases,
but thigh pain was present in 20% of patients. Thus, the advantages of the locking
stem in periprosthetic fractures are the high rate of healing, the rotational stability
afforded by the screws, and allowance of immediate weight-bearing and no detect-
able stem subsidence of the stem [54]. However, there are cases where the interlock-
ing screws may break. Learmonth reported breakage in 5 of 22 periprosthetic
fractures treated with the interlocking stem, attributing the failure to stems that were
too thin [55].
Special Considerations in B3 Fractures
The Vancouver B3 fracture poses the greatest challenge. In cases of deficient proxi-
mal bone stock and resulting devascularized bony fragments, several techniques
have been established to recreate the proximal femoral anatomy. Augmentation with
cortical strut allografts, impaction grafting, the use of allograft-prosthesis compos-
ites (APC), and proximal femoral replacements are all part of the surgeon’s arma-
mentarium to revise Vancouver B3 fractures.
Impaction grafting with or without mesh to contain it may be suitable for certain
fracture patterns below the level of the femoral isthmus and with significant com-
minution, bone loss, and unfavorable, ectatic femoral canal geometry that precludes
the use of long-stemmed implants. This technique was initially described for the
acetabulum in cases of protrusio. The technique involves impacting fresh cortico-
cancellous bone into the femoral canal to create a neo-endosteum prior to implanta-
tion of a cemented stem [56]. Certain patient populations, such as those with an
irradiated pelvis, are not good candidates for this procedure due to the lack of long-
term revascularization and osseointegration. Again, preoperative templating of the
native femoral canal is important to appreciate the size and length of the femoral
component. Lee et al. described a useful technique for grafting. The goal is to
bypass the fracture site by two cortical diameters with mesh. A cement restrictor is
first placed 2 cm distal to the location allowing for bypass of the fracture. Allograft
bone is then impacted against the restrictor to prepare the distal mantle of the pros-
thesis. By using smooth tapered reamers and broaches, the allograft bone can be
forced into the surrounding bony cortex to reconstitute the bone stock. Cementation
of the component is then performed. In their series of seven patients, 100% union
was achieved, and while the average subsidence of the femoral stem was 4.3 mm,
all components were deemed stable [57]. They chose this technique over a conven-
tional uncemented, long, fully porous-coated femoral component because they felt
that the femoral canal geometry at the isthmus precluded its use. Their concern was
that the fracture comminution at the level of the isthmus would not provide the nec-
essary length for scratch fit of the prosthesis in the femoral canal (4–8 cm) [56, 57].
By way of perspective, in a series of 26 cemented femoral revisions with intermedi-
ate 4–8-year follow-up, Fetzer et al. reported no femoral re-revisions in patients
with impaction grafting, citing no radiographically loose implants at final follow-up
[58]. However, other complications did arise including dislocation (12%) and sub-
sequent acetabular revision, as well postoperative femoral fractures (12%). In the
largest series of patients who underwent impaction grafting for B2 and B3 fractures,
Tsiridis et al. reported on 75 patients who received either a long or short stem with
or without grafting. Radiographs were analyzed for time to union. Of those treated
with long stems and impaction grafting, 88% united compared with 57.1% of the
short stems with grafting. The addition of grafting increased the likelihood of the
fracture uniting in the long-stem group. The mean length of time to union was
7.44 months (range 3–12) [59].
APCs, though falling out of favor as the megaprosthesis becomes more popular,
are another option for periprosthetic femur fractures in cases of poor proximal bone
stock. Causes of proximal bone loss that create this challenging clinical problem
include infection, osteolysis, stress shielding, and mechanical loosening [60]. APC
is indicated more for younger patients. Elderly patients who may not be able to
tolerate a lengthy operative procedure or who are unable to comply with weight-
bearing restrictions postoperatively are more appropriate candidates for a proximal
femoral replacement. As part of the preoperative planning, use scaled radiographs
to determine the approximate length of allograft needed. However, order allografts
longer than the measured femoral defect in anticipation of the need for intraopera-
tive adjustments to the graft. Finally, the allograft should have approximately the
same diameter as the host femur because gross mismatches between the host and
graft can lead to difficulty when seating the stem [61]. Moreover, if the graft is
slightly thinner than the host, the surgeon is able to telescope the graft into the host
bone to allow better fixation.
The femoral neck is divided approximately 1 cm proximal to the lesser trochanter
and a step-cut osteotomy made at the distal end to enhance rotational stability. If the
host trochanter with abductor attachment is available, the greater trochanter can be
osteotomized and removed. For adjustments in leg length, the distal portion of the
graft instead of the traditional neck cut is used. The graft is reamed with straight
rigid reamers and the femoral component cemented into the graft to ensure appropri-
ate anteversion of the prosthesis. Importantly, the host canal is more often wider than
the allograft. Therefore, the surgeon should choose an implant to fit the allograft,
because excessive reaming of the allograft to accommodate a larger prosthesis will
cause it to weaken. Attention is then turned to the host femur. The femur is exposed
via a trochanteric osteotomy. The bone is osteotomized to accept the osteotomy cre-
ated in the allograft. The prosthesis is cemented into the graft on the back table to
prevent any cement from entering the graft-host junction as this would interfere with
union and create an unwanted area of stress shielding [61]. The allograft prosthesis
is then inserted into the native femur, and cerclage cables are used to fix the junction.
The stem should bypass the osteotomy site by 2 cortical diameters or at least 4 cm
[62]. Cortical struts or even plates may be used as supplemental fixation if needed.
Few studies report long-term outcomes of APCs. Wang et al. retrospectively
reported the mid-term outcomes of 15 patients (4 of which were infected) who had
undergone the APC technique to reconstruct failed THAs. The average length of
allograft was 11 cm. At a mean follow-up period of 7.6 years, 10 patients (67%)
retained their allograft-prosthesis constructs which was considered a success. Union
was achieved radiographically in 13 (86%) patients. The average postoperative
Harris hip score improved from preoperative values. The other five patients had their
prosthesis removed because of either infection or failure [63]. Babis et al. reported
a slightly longer-term cohort with a 10-year survivorship of 69% for APC and sug-
gested that preoperative bone loss (Paprosky type IV), multiple previous hip revi-
sions, and the length of the utilized allograft were predictors of survivorship. The
use of the step-cut or intussusception technique was not statistically significant with
regard to outcomes. Complications associated with the use of APCs include disloca-
tion (3–54%), nonunion at the graft-host interface (4–20%), trochanteric nonunion
(25–27%), infection (3–8%), fracture (2–5%), and loosening (1–12%) [62].
a b c
Fig. 5.11 A 99-year-old female with a history of total hip replacement 15 years prior presents to
the emergency room after a fall. Anteroposterior (a) and lateral (b) radiographs of the proximal
femur show a periprosthetic fracture propagated through the cement mantle. Given the patient’s
age, and poor bone stock, a proximal femoral megaprosthesis was implanted (c). The remaining
abductor complex may be sutured to the prosthesis to preserve the lever arm of the abductors
The proximal femoral replacement (PFR), or megaprosthesis, remains a last-

ditch effort in cases where bony reconstruction is not possible (Fig. 5.11). Efforts
should be made to maximize the length of the native femur because the outcome of
PFR is influenced directly by the length of the remaining femur [64]. Careful preop-
erative planning to determine the length of the prosthesis is required. Some adjust-
ment may be made intraoperatively as modular components may add or remove
length. Length comes at a cost, however, as balancing the soft tissue tension with
stretch of the sciatic nerve is of paramount importance. To preserve the abductor
mechanism, the soft tissue should be sutured into the prosthesis as best as possible
to avoid issues with gait and abductor strengthening. The vasto-gluteal sling (vastus
lateralis-greater trochanter-gluteus medius) should be maintained when possible
[65]. For added protection, an abduction brace is usually used for 6 weeks postop-
eratively as the patient bears weight on the extremity.
Klein et al. reported the results of PFR following Vancouver B3 fractures. Of
their 21 patients, 20 were able to walk and had minimal pain at the most recent mean
follow-up of 3.2 years. The rate of complications, which included persistent wound
drainage requiring irrigation and debridement (two), dislocation (two), refracture of
the femur distal to the stem (one), and acetabular cage failure (one), was relatively
high [66]. To prevent the high rate of dislocation in the face of weakened or nonex-
istent abductors, the surgeon may opt to use a constrained liner. Importantly, this
requires that the acetabular component already be ingrown, as high-shear forces

imparted on a fresh acetabulum will cause early failure.
McLean et al. also retrospectively reviewed 20 patients, 15 of whom underwent
a PFR for a Vancouver B3 fracture or failed open reduction internal fixation of a
proximal femur fracture. Their mean age at the time of surgery was 72 years, and a
mean 12.5 years had elapsed from the time of their primary THA. At a mean 2-year
follow-up, there were six major complications: three patients suffered a postopera-
tive dislocation; two patients had persistent deep infection (present preoperatively);
and one patient suffered a periprosthetic fracture distal to the PFR stem [65]. Thus,
while PFR represents a reasonable salvage operation for Vancouver B3 fractures
and allows for immediate weight-bearing, there is still a high morbidity associated
with the procedure with little salvage if complications do occur.
Conclusion
In the face of an exponential rise in the number of total hip arthroplasties performed
in the United States, so grows the risk of periprosthetic fracture in a younger, more
active population as well as in older patients living longer with poor bone stock.
Arthroplasty and trauma surgeons alike must develop and hone the skills to treat
these complex injuries in the best interest of the patient. Preoperative planning is
critical in these cases. A key component of management involves the determination
of stem stability. If the stem is loose, most surgeons favor replacement of the stem
with a long, diaphyseal-fitting stem that bypasses the fracture. The overarching
goals of surgery are to restore mechanical stability, improve function, and provide a
stable, pain-free, weight-bearing joint. If a distally fixed monoblock or modular
stem is not suitable, reconstructive options such as impaction grafting, APCs, or
PFRs exist to reconstitute bone stock.
Authors’ Preferred Tips and Tricks for Periprosthetic Fractures Around a Loose
Femoral Stem
• Preoperative planning is the most important step in treatment of these injuries.
• Adequate exposure, delineating the extent and trajectory of the fracture lines.
• Placing a prophylactic cable distal to the fracture site to prevent fracture
propagation.
• Hand reaming if possible to avoid femoral canal blowout.
• Trialing stem and modules body/neck component prior to fracture reduction.
• Assessment of length and soft tissue tensioning using resting position of fracture
fragments as a guide.
• Assessing anteversion of modular body/neck using linea aspera or epicondylar
axis of the knee.
• Judicious use of supplemental plate fixation and screw spread using the pin,
pin—lag, lag—lock, lock algorithm.
• Assessment of construct position using intraoperative fluoroscopy.
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59. Tsiridis E, Narvani AA, Haddad FS, Timperley JA, Gie GA. Impaction femoral graft-

ing and cemented revision for periprosthetic femoral fractures. J Bone Joint Surg Br.
2003;86(8):1124–32.
60. Rassouli MR, Porat MD, Hozack WJ, Parvizi J. Proximal femoral replacement and allograft
prosthesis composite in the treatment of periprosthetic fractures with significant proximal bone
loss. J Orthop Surg. 2012;4(4):203–10.
61. Kellett CF, Boscainos PJ, Maury AC, Pressman A, Cayen B, Zalzal P, et al. Proximal femoral
allograft treatment of Vancouver type-B3 periprosthetic femoral fractures after total hip arthro-
plasty. Surgical technique. J Bone Joint Surg Am. 2007;89(Suppl 2 Pt 1):S68–79.
62. Babis GC, Sakellariou VI, O'Connor MI, Hanssen AD, Sim FH. Proximal femoral allograft-
prosthesis composites in revision hip replacement: a 12-year follow-up study. J Bone Joint
Surg Br. 2010;92(3):349–55.
63. Wang JW, Wang CJ. Proximal femoral allografts for bone deficiencies in revision hip arthro-
plasty: a medium-term follow-up study. J Arthroplast. 2004;19(7):845–52.
64. Parvizi J, Sim FH. Proximal femoral replacements with megaprostheses. Clin Orthop Relat
Res. 2004;420:169–75.
65. McLean AL, Patton JT, Moran M. Femoral replacement for salvage of periprosthetic fracture
around a total hip replacement. Injury. 2012;43(7):1166–9.
66. Klein GR, Parvizi J, Rapuri V, Wolf CF, Hozack WJ, Sharkey PF, et al. Proximal femoral replace-
ment for the treatment of periprosthetic fractures. J Bone Joint Surg Am. 2005;87(8):1777–81.
Part III
Interprosthetic, Interimplant and
Periprosthetic Fractures About the Knee
Chapter 6
Interprosthetic Fracture Fixation:
Achieving Stability and Union
Donald M. Adams, Robinson Pires,
Richard S. Yoon, and Frank A. Liporace
Introduction
In the United States, the population continues to increase, with a population over the
age of 44 estimated to be above 136 million by 2060. Nearly 98 million of these
patients are over 65 years of age [1–3]. With advanced age and an ever-increasing
elderly population comes an increase in the number of total joint arthroplasties [4].
With the decreased bone quality and increased propensity for falls, these patients are
at an increased risk for peri-implant, periprosthetic, and interprosthetic fractures [5, 6].
There is a lack in standardization of treatment in the literature surrounding these
complex interprosthetic fractures [7–9]. This chapter will review the basic princi-
ples and strategies of fixation applied to both simple and complex periprosthetic and
interprosthetic fractures. The author’s preferred methods of treatment, along with
specific case examples on how they achieved stability and union, will be discussed
for each type of periprosthetic and interprosthetic fracture. This complex scenario
also represents a new arena of research, as we continue to search for the ideal treat-
ment algorithm for this unique fracture case.
D. M. Adams · R. S. Yoon · F. A. Liporace (*)

Division of Orthopedic Trauma and Adult Reconstruction,
R. Pires
Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
Department of Orthopedic Trauma Surgery, Felicio Rocho Hospital, Belo Horizonte, Brazil

https://doi.org/10.1007/978-3-319-43008-9_6
100 D. M. Adams et al.
Interprosthetic Fractures of the Femur
The interprosthetic fracture that can occur between an ipsilateral TKA and THA is
rare, occurring in 1.25% of patients who have undergone both [10]. With the rise in
over a number of arthroplasties performed per year, the prevalence of these injuries
is on the rise. Additionally, interimplant fractures can occur between prior hardware
and an arthroplasty (i.e., short hip nail superior to an ipsilateral revision total knee
arthroplasty). Treating these complex situations has become increasingly difficult as
descriptions are scant and management strategies with their outcomes are rarely
reported [11, 12]. While treatment algorithms have been established for peripros-
thetic fractures about THA and TKA, only one attempt has been made at describing
and guiding interprosthetic femur fractures [13].
Decision-making between revision arthroplasty and fracture fixation is usually
guided by implant stability. General guidelines exist for revision arthroplasty in
unstable prostheses with or without open reduction and internal fixation. As previ-
ously discussed in the setting of a stable implant, treatment relies on biologically
friendly surgical exposure, ensuring vascularity, and fracture fixation with modified
techniques to accommodate arthroplasty components.
The interprosthetic fracture poses a unique challenge to surgeons. These injuries
are often in osteoporotic bone and in patients with multiple medical comorbidities.
Fixation with stable implants is usually geared toward spanning the fracture and the
at-risk stress riser zone between the implants. Care is taken not to destabilize the
implants and avoid potential secondary fractures. Goals follow the basic tenants of
restoring axial limb alignment with stable fixation to allow early range of motion,
promote fracture healing, and long-term stability of both prostheses without the
need for secondary procedure. To our knowledge, no studies have specifically evalu-
ated the location or results of interprosthetic femoral fracture treatment, with only a
few limited case results in the literature.
O’Toole et al. described LISS plating on five interprosthetic fractures [11]. No
description of fracture location or pattern was given nor were the specifics on surgi-
cal fixation or outcomes. Ricci et al. included four interprosthetic fractures in a
report on 24 minimally invasive supracondylar femur periprosthetic fractures [12].
Two of the four were fixed with long distal femoral locking plates spanning the
femur between TKA and THA. In the remaining two, shorter non-spanning plates
were used as the plate to femoral stem tip distance was sufficient to minimize stress
risers. No specific outcomes of either patient were discussed. Mamczak et al.
reported a greater tendency toward interprosthetic fractures in the supracondylar
region than in the diaphysis by a 2:1 ratio [8].
Femoral stress rising at or near surgical implants is well documented in total
joint literature representing a legitimate concern. However, the precise criterion for
defining a femoral stress riser is not yet known but has been associated with a
smaller gap size between femoral implants, length and stability of intramedullary
stems, and cortical width of the femur as it relates to metabolic bone disease, implant
selection, canal preparation, and prior surgeries and fractures of the femur [14–16].
Therefore, by logical reasoning, spanning the entire interprosthetic zone with a
6 Interprosthetic Fracture Fixation: Achieving Stability and Union 101
plate construct effectively eliminates the stress riser zone. Our preferred method of
fixation, especially in osteoporotic bone, is in accord with this theory, which involves
spanning the entire lateral length of the femur from the vastus ridge to the lateral
epicondyle of the distal femur.
Treating a supracondylar fracture with a retrograde IMN in the presence of a hip
prosthesis can lead to a high risk for an interprosthetic fracture between these two
intramedullary implants. An extramedullary implant might be better suited to stabi-
lize the fracture in such a situation [17].
Some authors have gone on to create custom IMN implants to help circumvent these
complications and allow for immediate weight-bearing. Grosso et al. reported out-
comes on two patients who underwent a custom coupling procedure between a THA
stem and DFR [18]. The authors reported successful outcomes, return to ambulation,
and range of motion at 14-month follow-up for both patients [18]. Newman et al. [19]
published a case report on a long custom intramedullary intercalating component that
was devised to link a well-fixed THA stem to a revision distal femoral component.
Lachiewicz [20] utilized a different type of custom interpositional femoral
device in the presence of a long-stemmed hip and constrained knee which prevented
fracture of loosening at 5-year follow-up. However, the patient’s range of motion
was severely limited to 30° of knee flexion. Finally, Tillman et al. examined a series
of four patients who underwent coupling of the distal and proximal femoral compo-
nents using a custom-made sleeve that cemented to the hip stem [21]. At 24-month
follow-up, they reported no complications related to mechanical failure, loosening,
or new infection. While these isolated case reports demonstrate adequate treatment,
the need for custom fabrication can delay patient care and is often not attainable.
Biomechanical tests have demonstrated that in osteoporotic bone the use of
orthogonal double plating by the addition of an anterior plate to a lateral plate
enhances construct stability [22, 23]. Müller et al. [24] went on to demonstrate that
the use of orthogonal locked plating was not associated with increased rates of com-
plication for periprosthetic femur fractures with stable implants. However, the
authors concluded that it should be used as a salvage procedure. Auston et al. [25]
further delineated that the anterior plate must be longer than seven holes, as all con-
structs in their study with less working length resulted in fracture.
Our approach to these complex fractures is guided by implant stability and bone
stock. We try to limit the use of cerclage wires and opt for more biologically friendly
fixation. Bryant et al. [26] published a series of interprosthetic fractures with similar
fixation strategies overlapping the components both proximally and distally with lat-
eral locking plates. The authors reported good outcomes and union rates. A recent
study by Brand et al. [2, 3] described how to use a modified drill bit to create a threaded
screw hole in the distal portion of a THA implant. The authors demonstrated in their
biomechanical study that linkage of a lateral plate to the THA prosthesis resulted in
significantly more stability that is adequate for immediate weight-bearing [2, 3].
The prior study supports our preferred method of linkage fixation of a retrograde
IMN with a lateral locking plate for osteoporotic bone. With increased stability
comes the ability to allow for early motion and weight-bearing, allowing for
improved outcomes.
Case Presentations
ase 1: Total Knee-Short IMN Interprosthetic Fracture – Revision

C
with Adjacent Interprosthetic Linked Fixation
An 89-year-old male fell sustaining an interimplant fracture between a short IMN

and a TKA (Fig. 6.1a, b). Here, the location of the fracture around the flange and
poor bone stock would have likely caused lateral plate fixation alone to fail second-
ary to excessive stress (Fig. 6.1c, d).
In this 89-year-old male, it is important to recognize the potential instability of
the knee implant with this fracture pattern. Under direct visualization, we intraop-
eratively stressed the implant and found it to be loose (Fig. 6.1a, b). Thus, the com-
ponent was subsequently revised. Since a short IMN was already in place from a
prior intertrochanteric fracture, the lateral plate was placed prophylactically to pro-
tect the osteoporotic bone from the increasing stress riser of a second implant. It is
important to note that the lateral plate was interlocked with the distal hole on the
a b c d
Fig. 6.1 (a, b) AP and lateral radiographs of an 89-year-old male who sustained a fall and suffered
a left total knee periprosthetic fracture with a short IMN in place proximally. Here, the location of
the fracture around the flange and poor bone stock would have likely caused lateral plate fixation
alone to fail secondary to excessive stress. (c, d) Intraoperative fluoroscopic images demonstrating
lateral plate placement and interlocking fixation with the IMN (arrows). AP, anteroposterior. IMN,
intramedullary nail
short nail creating a linked construct (Fig. 6.1c, d). This key concept creates
effectively one construct which then bypasses the stem of the femoral component to
its flare. It is essential to get bicortical fixation through the interlocking nail as well
as distal to the tip of the nail stem and proximal to the hinge stem allowing for a
smoother transition of stress. To continue to evenly distribute the stress and allow
the plate its maximum effectiveness, we prefer to maximize the working length of
the hybrid fixation by coming as close as possible in spanning the length of the
femur with the lateral plate. When possible, we continue to use bicortical screw
fixation, but when circumstances do not allow, unicortical locking screws can be
used. With balanced, stable fixation, the patient was made weight-bearing as toler-
ated postoperatively and has since gone on to uneventful healing.
ase 2: Total Knee Periprosthetic Fracture – Nail-Plate

C
Combination (NPC) with Prophylactic Neck Fixation
A 72-year-old dog walker fell sustaining a periprosthetic distal femur fracture

(Fig. 6.2a). The location of the fracture just proximal to the flange and poor bone
stock would have caused excessive stress to the implant and fixation type. Access
via a midline and medial parapatellar approach, the component was assessed and
deemed stable. The purpose of exhibiting this case in this chapter is to provide an
a b
120 mm
R R
Fig. 6.2 (a) AP and lateral radiographs of a 72-year-old osteopenic female who sustained a fall
and suffered a left total knee periprosthetic fracture. The location of the fracture just proximal to
the flange and poor bone stock would have caused excessive stress to the implant and fixation type.
(b) Postoperative images demonstrating lateral locking plate and retrograde IMN with linking fixa-
tion (arrows). Proximal prophylactic fixation of the femoral neck with two screws that were
through the plate. AP anteroposterior, IMN intramedullary nail
example of NPC fixation, where although there is no implant in the proximal femur,
spanning the femur and prophylactic fixation of the neck can help avoid future prox-
imal femur fracture.
To shift the neutral axis, a retrograde IMN was placed (Fig. 6.2b). To provide
further stability and to allow for femoral span and neck fixation, the retrograde IMN
and lateral locked plate were linked to create a single construct (Fig. 6.2b, arrows).
The patient was weight-bearing as tolerated immediately following surgery. The
patient was discharged within 24 hours postoperatively, went on to uneventful heal-
ing, and is doing well at 18-month follow-up.
ase 3: Interprosthetic Femur Fracture with a Poor Bone Stock

C
in Proximal Femur (Vancouver B3)
A 75-year-old female presented with a history of a low-energy fall. Radiographs

exhibited an interprosthetic fracture in between a seemingly loose THA with poor
bone stock and a stemmed revision-type TKA (Fig. 6.3a). Intraoperative assessment
of the proximal femoral component confirmed a loose implant with severe sur-
rounding osteolysis, requiring a proximal femur replacement (PFR). With the
patient in a lateral decubitus position, an extensive lateral approach was utilized.
Critical at this juncture of the case is calculating appropriate measurements prior to
removing the femoral component, by estimating the necessary length to restore
while judging the center of rotation of the hip; overlengthening or shortening the
affected limb can easily be avoided by taking this critical step.
Following your measurements, marking out the location of the cut under fluoro-
scopic imaging allows for facile transition to complete the following: simultane-
ously building the appropriately sized PFR trial and estimating (and allowing for)
the appropriate length plate to span both implants and prophylactically fix the femur.
If possible, leave the greater trochanter and its abductor sleeve in order to allow for
possible integration into the PFR; this can be achieved with heavy, non-absorbable
braided suture, or if amenable, a trochanteric plate with or without cables can also
be used.
Also important, in the setting of severe osteolysis, is to always assess the acetab-
ular component for stability. Here, the acetabular component was found to be stable
intraoperatively and not revised. The greater trochanter was preserved and cerclaged
to the PFR to maintain their function. The cerclage cables were placed distally to
prevent any unforeseen fractures from propagating. Meticulous care was taken to
allow cement mantel from the PFR to be in complete contact with that from the
TKA to reduce the stress riser and increase biomechanical strength.
Finally, a lateral plate was placed from the epicondyle to the proximal end of the
femur-PFR junction. This was done to overlap the zone between the two prostheses
in order to decrease the stress risers and allow a smooth zone of transition. The plate
was affixed proximally with cerclage wires and limited screw fixation, in order to
a b c
Fig. 6.3 (a) AP radiograph of a 75-year-old female transferred in from an outside institution status
post fall off demonstrating an interprosthetic fracture, exhibiting poor bone stock in the proximal
femur with a seemingly loose implant (Vancouver B3) fracture. (b) AP anteroposterior, PFR proxi-
mal femoral replacement. (c) AP and lateral postoperative radiographs demonstrating a PFR and
supplemental lateral locking plate
maintain the cement mantle and preserve biomechanical strength (Fig. 6.3b, c). The
patient was made weight-bearing as tolerated immediately and was discharged to a
subacute rehabilitation facility on postoperative day 3. Now, approximately 24
months following surgery, the patient walks with a walker at baseline and remains
independent, residing in a senior citizen residential complex.
Operative goals for these complex fractures, as with all fractures, is the proper resto-
ration of anatomic mechanical axis, alignment, and rotation. Obtaining preoperative
x-rays and CT can help for operative planning which should include an approach with
limited dissection. Appropriate preoperative workup (discussed in Chap. 1) allows

for appropriate planning and implant availability. Intraoperative assessment of stabil-
ity is the ultimate priority in order to avoid premature failure following surgery.
When using plate fixation, minimally invasive techniques are advantageous;
however, it is important to contour the plate’s morphology to the bone’s anatomy.
This will help with indirect reduction to the plate and avoid valgus malalignment in
supracondylar fractures. The plate should span both prosthesis and the total bone
from lateral epicondyle to the vastus ridge of the greater trochanter. Prior to fixation
of the plate, it is imperative to obtain fluoroscopy both proximally and distally to
ensure appropriate placement in orthogonal planes.
When a total joint is involved, revision components and plates should be avail-
able, and all implants must be operatively stressed under live fluoroscopy and
directly to ensure the implants are not loose or obscuring unrecognized fracture
lines. Primary total knee implants without a box or with an adequate opening in a
box can be treated with a retrograde nail that comes within 2 cm or less of the proxi-
mal implant. It is important to avoid common deformities of valgus and extension
seen with retrograde IMNs. Further stability can be added to the construct by apply-
ing a supplementary laterally based plate and, furthermore, by linking the plate to
the nail, creating additional biomechanical advantage.
Authors’ Preferred Method and Take-Home Points
Our preferred method of fixation that is used for all interprosthetic fractures is to
span the entire length of the femur with a laterally based plate spanning both
implants from lateral epicondyle to greater trochanter. When IMN placement is per-
formed or already in place, the plate is unitized with screws through both implants
to provide a linked construct.
DOs
Obtain complete radiographs and CT if needed.

• If implants are stable, consider indirect reduction techniques.
• Consider polyaxial implants and bone substitutes for augmentation.
• Span both implants and provide balanced fixation (appropriate spread and use of
non-locking, locking screws, and cables).
• Utilize indirect reduction techniques.
• When performing retrograde IMN for a distal femur fracture, a formal midline,
parapatellar arthrotomy allows for direct visualization of the starting point while
avoiding implant damage.
• Interdigitate screws through the lateral plate in the distal femur with the arthro-
plasty if possible.
DON’Ts
• Don’t use incompetent fixation.

• Don’t accept axis deviations → implant wear.
• Don’t leave loose implants.
• Don’t leave reamings in the joint.
• Don’t use screws only or non-balanced plate fixation.
• Don’t delay post-op ROM or weight-bearing.
• Don’t delay surgery in elderly.
Remember, the systemic manifestations are similar to hip fractures.
References
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2060: population Estimates and Projections, in, ed 2015. Washington D.C.: Census Bureau,
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stability in periprosthetic fractures of the femur – a biomechanical study. Med Eng Phys.
2014;36:239–43.
3. Brand S, Klotz J, Hassel T, et al. Intraprosthetic fixation techniques in the treatment of peri-
prosthetic fractures-a biomechanical study. World J Orthop. 2012;3:162–6.
4. Sidler-Maier CC, Waddell JP. Incidence and predisposing factors of periprosthetic proximal
femoral fractures: a literature review. Int Orthop. 2015;39:1673–82.
5. Lindahl H, Garellick G, Regner H, Herberts P, Malchau H. Three hundred and twenty-one
periprosthetic femoral fractures. J Bone Joint Surg Am. 2006;88:1215–22.
6. Lunebourg A, Mouhsine E, Cherix S, Ollivier M, Chevalley F, Wettstein M. Treatment of type
B periprosthetic femur fractures with curved non-locking plate with eccentric holes: retro-
spective study of 43 patients with minimum 1-year follow-up. Orthop Traumatol Surg Res.
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7. Kubiak EN, Haller JM, Kemper DD, Presson AP, Higgins TF, Horwitz DS. Does the lateral
plate need to overlap the stem to mitigate stress concentration when treating Vancouver C
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8. Mamczak CN, Gardner MJ, Bolhofner B, Borrelli J Jr, Streubel PN, Ricci WM. Interprosthetic
femoral fractures. J Orthop Trauma. 2010;24:740–4.
9. Moloney GB, Westrick ER, Siska PA, Tarkin IS. Treatment of periprosthetic femur fractures
around a well-fixed hip arthroplasty implant: span the whole bone. Arch Orthop Trauma Surg.
2014;134:9–14.
10. Kenny P, Rice J, Quinlan W. Interprosthetic fracture of the femoral shaft. J Arthroplast.
1998;13:361–4.
11. O'Toole RV, Gobezie R, Hwang R, et al. Low complication rate of LISS for femur fractures
adjacent to stable hip or knee arthroplasty. Clin Orthop Relat Res. 2006;450:203–10.
12. Ricci WM, Loftus T, Cox C, Borrelli J. Locked plates combined with minimally invasive inser-
tion technique for the treatment of periprosthetic supracondylar femur fractures above a total
knee arthroplasty. J Orthop Trauma. 2006;20:190–6.
13. Pires RE, de Toledo Lourenco PR, Labronici PJ, et al. Interprosthetic femoral fractures: pro-
posed new classification system and treatment algorithm. Injury. 2014;45(Suppl 5):S2–6.
14. Beals RK, Tower SS. Periprosthetic fractures of the femur. An analysis of 93 fractures. Clin
15. Iesaka K, Kummer FJ, Di Cesare PE. Stress risers between two ipsilateral intramedullary
stems: a finite-element and biomechanical analysis. J Arthroplast. 2005;20:386–91.
16. Larson JE, Chao EY, Fitzgerald RH. Bypassing femoral cortical defects with cemented intra-
medullary stems. J Orthop Res. 1991;9:414–21.
17. Lehmann W, Rupprecht M, Nuechtern J, et al. What is the risk of stress risers for interpros-
thetic fractures of the femur? A biomechanical analysis. Int Orthop. 2012;36:2441–6.
18. Grosso MJ, Lipman J, Bostrom MP. Coupling device and distal femoral replacement for peri-
prosthetic supracondylar femur fractures with an ipsilateral total knee and hip replacement.
HSS J. 2014;10:68–72.
19. Newman ET, Hug KT, Wellman SS, Bolognesi MP, Kelley SS. Custom intramedullary inter-
calating device for treatment of supracondylar fracture between constrained total knee arthro-
plasty and well-fixed total hip arthroplasty. Knee. 2014;21:594–6.
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and a long-stem total hip arthroplasty: treatment with a novel device. J Arthroplast.
2007;22:449–52.
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existing femoral component for the treatment of peri- and sub-prosthetic fracture. J Bone Joint
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Chapter 7
Periprosthetic Fractures Around Total
Knee Arthroplasty with a Stable
Femoral Component
John S. Hwang and Cory Collinge
Introduction
Distal femur fractures are increasingly common as our population ages and more
total knee arthroplasty (TKA) surgeries are used to treat arthritis. The incidence of
these fractures has been reported at 0.3–2.5% following TKA. There is also an
increasing incidence of interprosthetic fractures occurring above a TKA and below
a hip arthroplasty, which can necessitate treatments that are even more complex.
Risk factors for periprosthetic fracture around a TKA include osteopenia, rheuma-
toid arthritis, prolonged corticosteroid therapy, anterior notching of the femoral cor-
tex, and revision TKA. These scenarios present considerable challenges in treatment,
and no single management method has been identified to successfully overcome all
of the problems associated with these injuries.
Until the last few decades, most supracondylar femur fractures (periprosthetic or
not) were treated nonoperatively with or without cast bracing; however, angulatory
deformities, knee joint incongruity, loss of knee motion, and the complications of
immobility led to alternative treatments. More recently, both operative techniques
and implants have seen dramatic improvements, and internal fixation is now recom-
mended for most displaced distal femoral fractures in adults. The goals of treatment
are restoration of limb alignment, length, and rotation as well as stable fixation that
allows for early mobilization and healing. Nevertheless, internal fixation of peri-
prosthetic distal femur fractures may be difficult for several reasons. Thin cortices,
a wide medullary canal, compromised bone stock, and fracture comminution are
several contributors that render stable internal fixation difficult. Furthermore,
J. S. Hwang
Department of Orthopedics, Carolinas Medical Center, Charlotte, NC, USA
C. Collinge (*)
Orthopedic Specialty Associates, Ben Hogan Center,
Fort Worth, TX, USA

https://doi.org/10.1007/978-3-319-43008-9_7
110 J. S. Hwang and C. Collinge
t reatment may be further complicated due to issues in the use of knee prostheses, the
presence of previous surgical wounds, and pre-existing knee stiffness. Over the past
two decades, we have witnessed significant improvements in clinical outcomes as a
result of innovative implants and improved technique, yet the operative manage-
ment of these difficult fractures has not proved uniformly successful. Patients with
periprosthetic fractures have historically been treated with intramedullary nails or
plate-screw constructs. As stated, both of these modalities have seen improvements
in implant design and technical modifications, and yet, they still are not without
limitations when applied to osteoporotic bone around a TKA.
The mean age of patients with periprosthetic fractures tends to be higher than that
of those with non-implant-related fractures, as patients undergoing TKA tend to be
older and less active than the general population. Elderly patients typically present
with periprosthetic distal femur fracture cases resulting from low-energy trauma, and
mortality rates are similar to that of the hip fracture population. Patients with peri-
prosthetic distal femur fractures who also present with comorbidities such as demen-
tia, heart failure, advanced renal disease, and metastasis have shown to be independent
predictors of reduced survival when compared with age-matched controls. The age-
adjusted Charlson Comorbidity Index has demonstrated benefits in predicting sur-
vival for such a group of patients. In addition, a surgical delay of greater than 4 days
has also been shown to increase the 6-month and 1-year mortality rates [1, 2].
The objective of this chapter is to provide useful information for the orthopedic
surgeon who is treating a patient with a periprosthetic distal femur fracture. The
goals of this chapter are to improve the surgeon’s understanding of injury patterns,
enhance his/her decision-making process, and discuss modern surgical techniques,
including “tips and tricks,” that may assist in obtaining a good clinical outcome.
Classification
There are multiple classification systems for distal femur periprosthetic fracture
(discussed in-depth in Chap. 1). The most commonly used classification, developed
by Rorabeck and Taylor (Table 7.1), takes into account the fracture’s displacement
and prosthesis stability [3]. According to this classification, type I fractures should
be treated nonoperatively, type II fractures should be treated with internal fixation,
and type III fractures should require revision surgery. While this is currently the
most commonly used classification system, it falls short in its failure to consider
available bone stock a key factor in surgical decision-making.
Table 7.1 Rorabeck and Type Fracture displacement Component fixation

Taylor classification [3] of
I Undisplaced Well fixed
periprosthetic distal femur
fractures II Displaced Well fixed
III Undisplaced or displaced Loose
7 Periprosthetic Fractures Around Total Knee Arthroplasty with a Stable Femoral… 111
Table 7.2 Modified classification [4] of periprosthetic distal femur fractures

Type Fracture displacement Component fixation Bone stock in distal femur
IA Yes Well fixed Good
IB No Well fixed Good
II Yes/no Loose Good
III Yes/no Loose Poor
Kim et al. subsequently developed a classification system which took into con-
sideration distal femoral bone stock, as well as component fixation and fracture
displacement. Under this system, type II and type III fractures would require revi-
sion arthroplasties or distal femoral replacements (Table 7.2) [4]. Most recently, Su
et al. developed a classification system based primarily on the location of the frac-
ture. Type I fractures are proximal to the femoral component, while type II fractures
originate at the femoral knee component and extend proximally. Type III fractures
were defined as any fracture line distal to the upper edge of the anterior flange of the
femoral knee component [5].
Treatment Options
For the vast majority of patients, the ultimate goal of treatment for a periprosthetic
distal femur fracture is to achieve a painless, functional, and well-aligned lower
extremity that returns the patient to his/her state prior to injury. Treatment choice is
typically selected based on the stability and design of TKA implants, the presence
of any other implants, the quality and amount of bone stock, and the physical condi-
tion and ambulatory potential of the patient. Rarely, fracture repair or surgical treat-
ment at all is not feasible or desirable, and alternative treatments must be employed.
All of these considerations are explored in greater detail below.
Nonoperative Treatment
Historically, the standard nonoperative management of periprosthetic distal femur

fracture was skeletal traction with or without subsequent cast bracing. This changed
when improved results were noted with surgical treatment. Closed methods do offer
a way to avoid the risks of surgery itself; however, there are also a number of signifi-
cant and potentially severe risks associated with nonoperative treatment. For exam-
ple, complications from prolonged bed and limb immobilization include deep vein
thrombosis and pulmonary embolus, decubitus ulcer, pneumonia, urinary retention
and urosepsis, and others. Furthermore, studies have shown that these patients are at
high risk for malalignment/malunion and nonunion: for example, Culp et al.
reported that patients treated in prolonged traction had nonunion rates of 20% and
malunion rates of 23% [6]. Similar results were reported by Merkel and Johnson
who additionally noted that 35% of their patients went on to revision TKA [7].
Currently, nonoperative treatment is the treatment of choice for patients who
present with non-displaced fractures or those who are not surgical candidates due to
significant medical comorbidities such as those that are receiving palliative care.
Relative indications for nonoperative treatment include non-ambulatory states of
patients (e.g., paraplegia), significant underlying medical disease (e.g., severe car-
diopulmonary risk), lack of modern internal fixation devices, or imminent death. In
addition, surgeons who are unfamiliar or inexperienced with surgical techniques
should avoid operative management and elect to treat the patient nonoperatively
until the care of a surgeon experienced in periprosthetic fractures becomes available
to the patient.
Operative Treatment
Several surgical options are available to treat periprosthetic fractures of the distal
femur. If the implant is stable and enough bone is still available and attached to the
distal femoral component, then fracture repair with a plate or nail is recommended.
Even far distal fractures that extend distal to the proximal border of the femoral
TKA component can be successfully managed with internal fixation [8]. On the
other hand, if the prosthesis is loose or if scant bone is available distally, then revi-
sion arthroplasty (distal femoral replacement) may be chosen for salvage of this
difficult problem.
Achieving rigid internal fixation is potentially difficult—and sometimes impos-
sible—in osteopenic bone following a comminuted periprosthetic distal femur
fracture. Fixation method for distal femur fractures and periprosthetic fractures
has improved greatly over the past decade or two. Techniques focusing on the
preservation of biology and implants enabling improvement of stability in the
short, osteoporotic condylar segment are now the standards. In addition, implant
manufacturers are continuing to make improvements with each generation of
products.
One of the difficulties in the treatment of periprosthetic distal femur fractures is
the fixation limitation presented by the femoral component of the TKA. Fixation
methods are subject to the limitations posed by the design of the femoral compo-
nents. For example, retrograde nailing cannot be performed in femoral components
that have narrow or closed boxes, while certain fixed angled devices, such as a
95-degree blade plate or condylar screw, cannot be used in prostheses with deep
boxes. The evaluation of the prosthesis at hand is vital to constructing an appropri-
ate and optimal preoperative plan. Unfortunately, the information required for such
an evaluation is not always readily available to the surgeon as the number of galler-
ies displaying prostheses is very limited [9].
pen Reduction and Internal Fixation

O
(ORIF) Using Conventional Plates
The use of ORIF of periprosthetic distal femur fractures with conventional plates
rose in the 1970s and 1980s as techniques for periarticular fractures became more
common. The goals of ORIF for periprosthetic distal femur fractures with conven-
tional plates were anatomical reconstruction and early rehabilitation of the patient,
and several authors have reported “good” clinical results. Nevertheless, it should be
noted that these were small cohort studies with significant limitations.
Open anatomic reduction and internal fixation with traditional non-locked plates
has been associated with relatively high rates of delayed union, nonunion, and
infection, and the need for supplemental bone graft has been reported to be as high
as 90% in comminuted fractures treated in this manner. Healy et al. treated 20
patients with periprosthetic distal femur fractures with ORIF using a variety of
implants including blade plates, dynamic condylar screws, and condylar buttress
plates [10]. Most of these patients required autografts with index procedure. Those
grafted mostly healed, while those without graft did not, which led the authors to
recommend primary bone grafting with internal fixation to increase the prospects
for union.
With standard plating constructs, plating on one surface of a metaphyseal frac-
ture (eccentric stabilization) can be particularly prone to fixation failure.
Mechanically, the characteristic of the screw heads to toggle within the plate makes
it difficult for these implants to maintain coronal plane alignment, particularly with
opposite-cortex comminution. Additionally, because most plates are applied later-
ally, medial cortical comminution predisposes to loss of reduction into a varus
deformity when standard implants are used [11]. Figgie et al. reported nonunions in
five of ten patients with a periprosthetic distal femur fracture treated with ORIF, and
eight of the ten cases subsequently fell into varus alignment despite satisfactory
intraoperative alignment [12].
Locked Plating
Modern locked plating technology was proposed largely to address the difficulties
with treatment of osteoporotic, metaphyseal fractures such as those discussed in this
chapter. Locked plates allow the screw heads to screw into the plate, creating “fixed-
angle” constructs, which are theoretically better able to resist varus displacement
forces across the fracture (Fig. 7.1a–c). Most surgeons will agree that these implants
have provided an excellent tool to achieve stable fixation in many osteoporotic frac-
tures, including periprosthetic fractures. A well-fixed prosthesis is an essential pre-
requisite for predictably treating with locked plating systems.
Biomechanical studies using paired cadaver femurs have demonstrated that fixa-
tion with locked plates is superior to those with plates that use non-locked screws,
a b
Fig. 7.1 (a) Injury radiographs of a periprosthetic distal femur fracture above a stable knee
replacement in a 79-year-old woman. (b) Postoperative X-rays show treatment with a locked plate.
(c) At final follow-up at 14 months, radiographs show a well-healed fracture and the patient was
doing well clinically
such as blade plates and dynamic condylar screws. Various clinical studies have
demonstrated union rates to be between 78%–100% with locked plating systems [8,
13–18], as opposed to the poorer results seen in nonoperative management or con-
ventional plating systems. For example, Kregor et al. reported 100% union rate in
13 periprosthetic fractures using locked plating; only 1 patient needed bone grafting
[17]. Raab and Davis reported their results of using locked plating in 11 fractures,
which included 2 nonunions: 8 fractures were supplemented with nonstructural
allograft [18]. The authors reported union in all nine acute fractures and in one of
two cases of nonunion with satisfactory alignment. Finally, Streubel et al. evaluated
far distal periprosthetic supracondylar fractures of the femur and concluded they are
not a contraindication to repair with lateral locked plating [8]. Patients were divided
into those with fractures located proximal to the implant (28) and those with frac-
tures that extended distal to the proximal border of the femoral component (33).
Delayed healing and nonunion occurred in five (18%) and three (11%) of more
proximal fractures, respectively, and in two (6%) and five (15%) of the fractures
with distal extension (p = 0.23 for delayed healing; p = 0.72 for nonunion), respec-
tively. Four construct failures (14%) occurred in more proximal fractures and three
(9%) in fractures with distal extension (p = 0.51).
The development of the LISS system and indirect plating systems and techniques
has allowed for better management of maintaining biology and allowing for better
union rates. Ricci et al. reported the results of treating 22 periprosthetic fractures by
indirect reduction methods without bone graft using locked plating. Nineteen of 22
fractures (86%) healed after the index procedure. All three patients who failed to
heal were insulin-dependent diabetes mellitus patients. Two of these patients devel-
oped infected nonunion. Authors concluded that fixation of periprosthetic supracon-
dylar femur fractures with an indirect locked plating provided satisfactory results in
nondiabetic patients [13]. O’Toole et al. examined nine periprosthetic fracture
above a TKA and five patients with hip and knee arthroplasty treated with LISS
plating. The average age of the patients were 80, and all were female, and no com-
plications were seen in this study.
Literature has demonstrated that LISS for supracondylar distal femur fractures
allows for early range of motion and more rapid bone healing [19, 20]. Falck et al.,
demonstrated reduction in angalgesic use and accelerated mobilization in patients
treated with LISS [21]. Althausen et al. reported better results using LISS to main-
tain alignment and return to preoperative functional status when compared with
other devices for periprosthetic distal femur fractures. All patients maintained phys-
iologic valgus and length [22]. A recent study by Hierholzer et al. compared 115
patients with distal femur fractures that included but no limited to patients who
suffered periprosthetic fracture around a total knee implant. They compared retro-
grade nailing with LISS plating and found no difference in fracture healing, non-
union, and infection between the two. These authors suggest precise preoperative
planning and advanced surgical experience to reduce risk of revision surgery [23].
Although the mechanical basis for locked plating seemed well-suited for the
osteoporotic metaphyseal fracture, it has not exactly turned out to be the panacea for
which many had hoped. The vast majority of surgeons have transitioned to using
locked plates for these fractures, but this appears based on anecdotal observations
and lower-quality studies—there remains a paucity of clear, high-level evidence
proving their benefit [24]. Even though the screw heads mechanically lock to the
plate, in order for the fixation to remain stable, the screw shafts must remain securely
anchored in the epiphyseal, periarticular bone segment. For this to occur, there
needs to be an adequate volume of bone with adequate quality to provide anchorage.

The supracondylar periprosthetic femur fracture with distal extension adjacent to
the prosthesis may have limited native bone stock available for placing effective
locked screws. Hoffmann et al. reported a nonunion rate of 22% in 36 patients who
underwent locked plating for periprosthetic distal femur fracture [16]. Ebraheim
et al. found a complication rate of 37% following distal femoral locked plating for
periprosthetic distal femur fractures, including delayed union (7.4%), nonunion
(3.7%), and failure of fixation (26%) [25].
Intramedullary (IMN) Fixation
Our experience and the available literature suggest that retrograde IMN is a safe
and minimally invasive procedure that allows for early healing of this injury pat-
tern in most patients (Fig. 7.2a–c). Many studies have now shown high success
rate with the use of retrograde nail in the management of periprosthetic fractures
of the distal femur. A cadaveric study has reported greater fracture stability with
the use of a retrograde nail as compared with less invasive stabilization systems
in simulated periprosthetic fractures [26]. This technique allows for the use of
the previous incision, with no soft tissue dissection being required at the fracture
site, which preserves blood supply and biology. It allows early mobilization and
range-of-motion exercises of the knee joint and maintains the overall alignment
at the fracture site. A recent systematic review of 415 cases of periprosthetic
fracture above TKA reported that retrograde nailing is associated with relative
risk reduction of 87% for developing a nonunion and 70% for requiring revision
surgery when compared with traditional (non-locked) plating methods [27].
Wick et al. demonstrated that both LISS plating and retrograde nailing are useful
techniques in treating periprosthetic distal femur fracture. They did note that
LISS plating was preferred in osteoporotic bone or fractures with short distal
segments [28].
However, this technique also has some limitations. The reasonably common
limitation of retrograde nailing for periprosthetic distal femur fracture is that the
intercondylar box of the femoral component renders nailing impossible. This is
more common with older implants and less problematic with newer versions.
Others may have a narrow fit which may push the nail entry site posterior: this
may impart an extension deformity at the fracture site (Fig. 7.5). In these cases,
plate fixation may be the better option. In addition, as previously discussed, it is
not possible to use a retrograde nail in a very distal fracture, as it may not provide
any fixation to the distal screws. A retrograde nail should not be used in the pres-
ence of a pre-existing total hip replacement, as it can create a stress riser below the
femoral stem, which may, in turn, lead to a fracture between the two implants.
Although most of the modern knee prostheses would allow insertion of a retro-
grade nail, it is important to determine the type of the knee implant prior to
surgery.
a b
Fig. 7.2 (a) Injury radiographs of a comminuted periprosthetic distal femur fracture and with a
stable prosthesis in an 83-year-old woman. (b) Postoperative radiographs show fixation with a
modern retrograde femoral nail with locking screw capability. (c) Final follow-up X-rays at
15 months post-injury show a well-aligned and healed femur (Case courtesy of Ken Koval, MD)
evision Total Knee Arthroplasty (AKA Tumor

R
Prosthesis or Distal Femoral Replacement)
Revision TKA is typically reserved for patients who have extremely distal fractures,
significant comminution where secure fixation cannot be achieved, or there are
loose or unstable femoral components (Fig. 7.3a, b). Typically, either long-stemmed
revision components or distal femoral replacements are used [29]. These prostheses
can provide stable fixation that allows for early weight-bearing and range of motion.
a b c
d e
Fig. 7.3 (a) Extreme case of a 49-year-old, previously active woman in an auto accident incurring
polytrauma, including a highly comminuted and open periprosthetic distal femur fracture. Some
components of instability are present such as interprosthetic comminution (arrows). (b)
Postoperative X-rays show repair using a surgical extension of the open fracture and the combina-
tion of a retrograde femoral nail and lateral locking plate. (c) Final follow-up shows well-healed
X-rays. The clinical outcome was good, as well. (d) AP and (e) lateral postoperative radiographs
following nail-plate combination technique utilizing a short segment plate for additional support in
the setting of severe metaphyseal comminution
Satisfactory results have been demonstrated using revision implants (i.e., distal
femoral replacement [DFR]) following periprosthetic distal femur fractures in a
number of limited studies. For example, Cordeiro et al. reported on nine patients
with periprosthetic distal femur fractures: they found that patients who underwent
DFR had better results in walking ability, range of motion, and early rehabilitation
when compared to those treated nonoperatively or with conventional plating [30].
Pour et al. examined 44 patients with hinged prostheses used in revision cases,
including 4 patients with periprosthetic fracture, and found 79.6% survival rate at
1 year and 68.2% at 5 years [31]. Chen et al. in a review of 12 published reports
including 195 patients noted successful results in 10 of 11 cases who were treated
with DFR as initial treatment for a periprosthetic distal femur fracture. However,
there was a complication rate of 25% which included a knee dislocation [32].
When significant bone loss is present, long-stemmed revision has also been used
in with allografts. Kassab et al. reviewed 12 consecutive patients, 2 lost to follow-
up, who underwent revision arthroplasty with distal femoral allograft. They found
good to fair results in HSS knee score and reported the mean range of motion to be
98° (range 50–115°). Nine patients reached full union [33]. A more recent study by
Saidi et al. compared allograft prosthesis composite (APC), revisions systems, and
DFR. It was found that the patients with APCs had the most blood loss, longest
operative time, and longest hospital stay. The authors recommend the use of DFR as
opposed to APC and revision systems in patients with extreme bone deficiency and
advanced patient age [34].
The DFR implant should be considered as a limb-salvage option when all other
surgical options are unlikely to be successful. Recently, a retrospective review by
Rahman et al. examined the use of DFR of periprosthetic supracondylar fractures.
They found mean final range of motion to be 2–90.2° and moderate patient satisfac-
tion and function. As previously discussed, Saidi et al. recommended DFRs over
APC and revision systems. The disadvantage of using DFR is the early rates of
aseptic loosening, and thus, it may not be suitable for younger patients. Some rela-
tive indications for DFRs are older patients, sick patients who may not tolerate more
than one procedure, and patients with osteopenia with significant bone loss.
Case Presentations
Issues, Controversies, and Problems
Case 1: Periprosthetic distal femur fracture treated with plates and screws
An 83-year-old woman fell onto her flexed knee and, based on her AP and lateral
femur/knee radiographs, suffered a comminuted periprosthetic distal femur fracture
above a stable TKA (Fig. 7.1a). Corresponding radiographs after she was treated
with locked plating (Fig. 7.1b) using a bridge-plating technique are exhibited. At
5-month follow-up, she was clinically and radiographically healed (Fig. 7.1c) and
very satisfied with her outcome.
Case 2: Periprosthetic distal femur fracture treated with retrograde femoral nail
A 83-year-old woman fell down a stair and suffered a comminuted distal femur
fracture above a well-fixed femoral component that was compatible for nailing
(Fig. 7.2a). She was treated with retrograde femoral nailing (Fig. 7.2b) using four
fixed-angle distal locking screws (Phoenix®, Biomet, Parsippany, NJ). At 6-month
follow-up, she was clinically and radiographically (Fig. 7.2c) healed and ambula-
tory to her pre-injury level.
Case 3: Massively unstable fracture in a young patient treated with nail-plate
construct
A 49-year-old morbidly obese woman with a TKA was involved in a motor vehi-
cle accident and suffered polytrauma. The TKA was recognized as likely to be
unstable with standard fixation (Fig. 7.3), but distal femoral replacement appeared
unsatisfactory treatment choice due to the patient age and size. AP and lateral radio-
graphs (a,b) and CT (c) reconstruction show osteopenia and limited bone stock
associated with femoral component. The patient was treated with staged surgery
using an external fixator and ultimately underwent ORIF with an arthrotomy and
repair with a nail-plate construct (Fig. 7.3d, e).
Case 4: Periprosthetic distal femur fracture treated with locked plating resulting in
nonunion
Radiographs of a 68-year-old woman with low-energy mechanism suffered a
distal femur fracture (Fig. 7.4a) which was treated with locked plating (Fig. 7.4b).
She went on to develop an atrophic nonunion (Fig. 7.4c). Hypovitaminosis D was
diagnosed and she was treated. Revision surgery included compression of the non-
union with a 95-degree angled blade plate and autograft. X-rays from 6 months
show that she healed reasonably quickly thereafter (Fig. 7.4e).
Case 5: Nail causing extension deformity
Lateral knee X-ray of a nailed periprosthetic femur fracture exhibits where the
arthroplasty implant forced the insertion point posterior. This may create and exten-
sion deformity as the nail crosses the fracture as seen in Fig. 7.5.
Surgical Planning and Technique
Due to the large spectrum of periprosthetic distal femur fractures, no single implant
or approach will be optimal for every case. The method of fixation should be based
on a preoperative plan that incorporates the fracture pattern, soft tissue injury,
patient factors, surgeon preference/familiarity, and hospital resources (Fig. 7.6). As
such, thorough assessment of the patients must be performed, and plain radiographs
a b c
d e
Fig. 7.4 Radiographs of a 68-year-old woman who had a periprosthetic distal femur fracture (a)
treated with locked plating (b), which went on to nonunion (c). Nonunion was treated with revision
to a 95-degree angle blade plate and autologous bone grafting (d). The distal femur fracture finally
was healed at 15 months despite being complicated further by an associated hip fracture treated
with hip arthroplasty (e)
Fig. 7.5 Lateral
radiographs that
demonstrate postoperative
recurvatum deformity that
may occur as the result of a
posterior start point (black
arrow) resulting in a poor
reamer path during
retrograde nailing
Fig. 7.6 Preoperative planning part of

successfully treating patients with periprosthetic
distal femur fractures. It improves surgical
efficiency and predictable clinical results over time
Post
Ant
4mm drill/tap
Post look into cement
+/-
Fill holes
augment
with cement
must be scrutinized to assess the “personality” of the fracture. Quality images must
be obtained (Fig. 7.7a), and occasionally advanced imaging with computed tomog-
raphy (CT) is helpful. The sequential steps in the surgical management of peripros-
thetic distal femoral fractures include (1) restoration of the articular surface, if
needed, (2) stable internal fixation, (3) grafting of bone loss (rare), (4) impaction of
a b
Fig. 7.7 (a) Injury AP and lateral radiographs of a 74-year-old man with a periprosthetic distal
femur fracture and a stable knee prosthesis. (b) A biology-preserving lateral approach is taken to
reduce the fracture and apply implants. (c) Reduction is achieved with a femoral distractor to gain
and hold length and rotation, a knee roll to control flexion-extension, and a clamp to control trans-
lation in this case. (d) Intraoperative imaging correlating to photo “c” demonstrating reduction. A
screw has been inserted cranial to the fracture to compress the bone to the plate. (e) Intraoperative
picture shows plate fixation with preservation of biology to facilitate healing. (f) Postoperative
imaging shows quality alignment and fixation with locked plating method
the fracture in severely osteoporotic elderly patients, (5) early range of motion of
the knee, and (6) delayed protected weight-bearing.
The vast majority of periprosthetic distal femur fractures are best treated with
internal fixation. We recommend either locked plating or closed retrograde intra-
medullary nailing. Regardless of the implant used, the goal is anatomic reduction of
the joint surface and stable internal fixation, which will allow early range of knee
motion. In isolated closed fractures, internal fixation should be performed within
the first 24–48 h. If surgery must be delayed for more than 24–36 h, a temporary
external fixator or tibial pin traction should be considered.
While the basic principles of treatment are similar with both a plate and an intra-
medullary nail, the devices achieve fixation differently and, thus, have different
technical methods of application and risks of usage. Restoration of alignment and
preservation of fracture biology are two basic principles of treatment that cannot be
overemphasized. A predictably good long-term outcome is certainly less or not at
all likely if these surgical priorities are not heeded. The specific usage of locked
plates or nails, as well as an algorithm for fracture reduction, should be well thought
out as part of the preoperative treatment plan. Some tips on avoiding complications
are presented in Table 7.3.
Table 7.3 Technical tips for planning periprosthetic distal femur fracture surgery
Prevent medical complications Medical clearance/risk assessment
Assess bone quality Assess plain X-rays, history
Assess for implant stability Quality plain X-rays
Assess for compatibility with Medical records, joint replacement staff, online database
intramedullary nailing, if chosen
Malalignment: Intraoperative diligence is key!
Contralateral side is a good guide
Pharmacologic paralysis with anesthesia
Varus-valgus Intraoperative guides, Bovie cord
Flexion-extension Quality lateral fluoroscopy, well positioned bolster/
bump, posterior cortical read (“constant fragment”)
Rotational Cortical reads, rotational profiles (compare to
contralateral side)
Translation Well positioned bolster/bump, joystick, plate position
Length Cortical reads, radiolucent ruler
Construct decisions
Mechanical environment More comminuted, osteoporotic fractures > bridging
plate construct
Stability Long plates, increased number, well-spaced and/or
locked screws
Balanced fixation Similar “density” of fixation proximal and distal to fracture
Augmentation of standard implants Combine nail and plate, add cements for screw
augmentation (CaPO4 or PMMA)
Interfacing with pre-existing implants Overlap implants where possible
Avoid irritable implants Avoid long screws around knee, roll-over view
Avoid knee stiffness Stable repair (pain control), early range of motion
A biology-preserving procedure should be done. We see little biologic cost in

terms of fracture healing from a thoughtful parapatellar arthrotomy or lateral
approach to the distal femur as long as good technique is used, including avoiding
soft tissue stripping, preserving perforators if possible, debriding the fracture site
(including hematoma), etc. We will also frequently use radiolucent guides for per-
cutaneous plate application, but the objectives of fracture reduction and bridge-
plating must be successfully attained.
The preoperative plan should also take into consideration how intraoperative
imaging will be used. High-quality radiographs are absolutely critical for proper
implant placement into the femoral condyles, and preventable errors may adversely
affect outcomes. C-arm is brought in from the contralateral “well” side (Fig. 7.7b, c).
Before draping, the C-arm should be brought in to confirm that correct views can be
obtained, unhindered by overlap of the contralateral limb. A quality image of the
opposite “well” limb is often useful as a template for repair.
General endotracheal anesthesia is preferred to allow for complete muscle paral-
ysis; however, spinal or other regional techniques are occasionally indicated. The
patient is positioned supine on a radiolucent flat-top (Jackson) table. The anesthesia
team should understand that complete muscle paralysis is necessary to help regain
length and overcome the powerful deforming muscle forces crossing the fracture.
The entire limb is draped free into the field to allow manipulation of the extremity,
which will also assist intraoperative fluoroscopy.
Locked Plating
When using plate fixation, accurate fracture reduction is a vital component in restor-
ing normal function and allowing for early mobilization. Each implant and tech-
nique has its own inherent benefits and pitfalls when used for periprosthetic distal
femur fractures.
Anatomically contoured plates must be used thoughtfully, as a number of pitfalls
are possible. Not all patients match the plate anatomy, and this mismatch can impart
deformity. Plates may occasionally need to be bent or applied off of the bone to
allow for anatomic reduction. If the plate does fit, it must be applied in the proper
position on the bone, as misapplication also leads to deformity. For example, a plate
applied in an overly distal or posterior manner will push the condyles medially,
thereby resulting in the “golf-club” deformity: in general, a plate secured to the
condyles in a non-anatomic position is likely to promulgate deformity across the
fracture.
Indirect reduction of the metaphyseal or metadiaphyseal portion of the fracture
is achieved by a combination of methods (Fig. 7.7b–d). In simple fracture patterns,
reduction using manual longitudinal traction alone may suffice. A well-placed
pointed reduction forceps or “King Tong” clamp can also aid reduction by holding
the fracture in proper position. The authors have found the universal (femoral) dis-
tractor to be a valuable tool. Placed anteriorly into the femoral shaft proximally and
anchored in the proximal tibia, distraction usually restores overall length and
alignment. Initial overdistraction permits gentle teasing of comminuted fracture

fragments into near-anatomic position. A large or medium sterile towel roll or bump
can be effective at controlling sagittal alignment; moving it distally or proximally
even a few centimeters may be very helpful. Finally, if correctly applied, periarticu-
lar plates can fine-tune the reduction by pulling the bone to the anatomically con-
toured plate using conventional screws. Combining standard cortical screws to lag
the bone to the plate followed by locked screws to aid in construct stability is a
useful tactic and employs benefits of both screw types. It is important to remember
that if a combination of non-locked screws and locked screws is used in any given
fracture fragment, the non-locked screws must be inserted first in that fragment
before any locking screws are inserted (“lag before you lock”), or the fixation of the
non-locked screws can be compromised.
Plate application has become more complex with the introduction of locked
implants, but also potentially more effective with multiple options for screw place-
ment. Screws can be standard or locked, cannulated or noncannulated, or bicortical
or unicortical, and plates can be inserted open or through minimally invasive
approaches. The variety of screw options has become especially useful for peripros-
thetic distal femur fracture because of the limited bone stock and distal femoral
prosthesis. When using most plates (not polyaxial) as a reduction tool, it is impor-
tant to align the most distal locked screws or their guidewires parallel to the knee
joint to ensure that the 5–8° or so of valgus built into the plate is achieved. Plates
with polyaxial screws also have similar alignment guides to ensure restoration of
the appropriate valgus alignment, but these and subsequent condylar screws must be
applied thoughtfully. All non-locked screws must be inserted into the proximal or
distal segment before any locked screws are placed. If a periprosthetic fracture is
well reduced and has particularly good bone quality, compression could be applied
to increase stability, promote primary bone healing, and allow for earlier weight-
bearing. Nonetheless, only when the medial cortex is restored can the plate be effec-
tively loaded. Properly done, the plate is placed under tension and in theory subject
to load sharing, rather than load-bearing. Much more typically, in cases with com-
minution, the plate is fixed to the proximal and distal fracture, bridging the zone of
comminution (Fig. 7.7e, f). In this environment, the plate acts as an internal splint.
However, the fracture fragments spanned by the plate are left undisturbed and capa-
ble of rapid consolidation if their soft tissue attachments have been respected. In
cases of severe osteoporosis where the patient is non-ambulatory or must bear
weight immediately, acute shortening with compression across the metaphyseal
fracture may be chosen. While this may maximize bone to bone contact, the surgeon
should still be aware that the fracture stability may soon be lost by resorption and
further “settling” of fragments with micromotion.
In comminuted fracture patterns, reduction can be achieved with the aid of a
femoral distractor or an external fixator. Most of the reduction methods used for
simple fractures are applicable to comminuted fractures. We have found that it is
often easier to reduce the fracture to the plate rather than the plate to the fracture in
complex fracture patterns. In this situation the plate must be used to aid reduction.
It is important to reemphasize that the most distal locked screws must be parallel to
the joint surface as assessed on AP image as a guide for restoring limb alignment.
The length of the plate and the number and placement of screws are based on the
preoperative plan. In general, we favor treating comminuted and osteoporotic frac-
tures with less soft tissue dissection, longer plates, more screws in each segment,
and more locked screws. In general, a longer plate with spaced screws provides
better mechanical stability compared with shorter plates and clustered screws.
When selecting plate length, eight cortices of fixation above and below the fracture
site are recommended to provide adequate stability to prevent early torsional and
axial failure. This may not always be possible in the distal segment because of the
femoral prosthesis. The use of longer plates with well-spaced cortical screws limits
implant stiffness and encourages secondary bone healing. If a locked construct is
chosen, a plate of sufficient length to allow no more than 50% of screw holes to be
filled is required to prevent stress concentration and premature implant breakage. If
the fracture is located between prostheses, the proximal femoral component should
be spanned in order to prevent stress riser between the junctions of the implants. The
plate is centered on the lateral aspect of the femur, and a K-wire is applied in a wire
hole in the plate (if available) or cannulated wire guide. With the plate centered on
the distal diaphyseal fracture fragment, it is provisionally fixed close to the fracture.
Intraoperative fluoroscopy is used to confirm fracture alignment and implant posi-
tion. The guide pin closest to the joint is typically designed to restore varus–valgus
alignment if placed parallel to the joint axis. A series of cortical screws followed by
locked screws (hybrid technique) allows the benefits of both screw types to be real-
ized. The condylar segment is stabilized predominately with locked screws.
Retrograde Intramedullary Nailing
The main potential advantage of retrograde nailing over plating is that they may be
inserted through smaller, potentially less invasive surgical approaches than plates,
and the devices are centrally placed so that bending forces may be better resisted.
Keys to successful nailing in the distal femur as well as elsewhere are (1) optimizing
the starting point and initial reamer pass and (2) obtaining and maintaining a quality
reduction during the procedure.
There are several potential advantages of nailing over plating: it is a load-sharing
device compared with a plate and has the potential to stabilize complex fractures
with less soft tissue dissection. Modern nailing systems now allow multiple distal
screws in different planes and rigid locking capability to improve stabilization of the
condylar block compared to a decade ago. These are particularly advantageous due
to their ability to work around the prosthesis. Surgeons currently favor full-length
nails inserted beyond the isthmus of the femur to the level or just above the lesser
trochanter to prevent residual instability or fractures above short nails.
Potential disadvantages of retrograde nailing include knee sepsis, stiffness, and
patella and femoral pain. Additionally, the starting point may be difficult to ascer-
tain through standard fluoroscopy due to the femoral prosthesis.
Technique of Intramedullary Nailing
The goals of intramedullary nailing remain the same as for plating restoration of
axial alignment and length, fracture stabilization, and maintenance of a biologic
environment conducive to healing with avoidance of infection. Surgery is done on a
radiolucent table with the aid of an image intensifier.
The patient is positioned supine and the affected limb supported on a radiolucent
triangle or large bump to a 20- or 30-degree angle. The C-arm unit should come in
from the opposite side of the table, and the underside of the table should be clear to
move the C-arm from the hip to knee without obstruction in both the AP and lateral
projection. When possible the fracture should be reduced before nailing. Many of
the indirect reduction methods described in femoral plating are useful for nailing.
Intramedullary nailing is usually performed through the previous incision. The
arthrotomy will usually be performed in the direction that was used for the TKA, if
that can be determined. If there is knee contracture, a wider incision is made to
facilitate access to the intercondylar notch. The intramedullary nail can then be
inserted through the open incision. It is important to leave 5–6 mm of capsular tis-
sue for a stable side-to-side repair during closure. The patella and local soft tissues
should be protected from reamers and other instrumentation during nailing. A work-
ing “soft tissue” cannula is available in most nailing sets, or carefully placed right-
angle retractors are effective.
Metaphyseal fracture reduction is performed manually or using the femoral dis-
tractor with pins placed eccentrically or unicortically in the shaft, a well-placed
sterile towel roll, and Schanz pins attached to a T-handle chuck (joysticks) in the
femoral shaft or condyles, to reduce the major fragments.
In a native knee, the optimal portal of entry for the nail is in the intercondylar
notch at the junction of Blumensaat’s line and the subchondral line of the distal
femoral trochlea. Obviously the standard technique to obtain the starting point is not
a feasible option when a prosthesis is in place. The use of an AP and lateral view,
aiming for the center of the canal, provides an adequate reference point. In addition,
if the prosthesis was appropriately centered, the starting point on the AP should be
the same. It may be necessary to remove cement within the canal if it is blocking the
entry point. In addition, careful attention must be paid while nailing in order to
prevent damage to the prosthesis. A threaded tipped guide pin and cannulated drill
are used to open the distal femur before nailing. The pin is carefully inserted in line
with the femoral shaft to ensure restoration of coronal plane alignment on the AP
image. Once the guide pin placement is confirmed with AP and lateral radiographs,
the step reamer is advanced through the working channel soft tissue sleeve over the
entry wire to prepare the insertion site. Occasionally, an “open” notch femoral
implant will push the nail insertion point somewhat posteriorly. We feel that few
millimeters of posterior translation is quite acceptable, but one must be watchful,
and in the rare occasion where the starting point is significantly altered, the surgeon
should consider aborting nailing in favor of plating.
A beaded tip guidewire is inserted into the intramedullary canal and advanced
past the fracture site, into the proximal femur under fluoroscopic control. With the
fracture reduced, the position of the guidewire should be center-center in both the
AP and lateral views in both the proximal and distal fragments. An intramedullary
fracture reducer or “finger” is available in most nailing sets and can be used to facili-
tate reduction and guide wire passage across the fracture site. Blocking screws are
sometimes used to narrow the effective canal diameter of distal femur to improve
alignment and prevent deformity. Although impossible in some cases, blocking
screws can be placed in the distal segment to help reduce coronal or sagittal plane
deformity. A rule of thumb is to apply the screws on the concave side of existing
deformity.
Summary
In conclusion, management of periprosthetic fractures of the femur above TKA

depends on bone quality, fracture characteristics, size of distal fragment, stability of
the implants, and condition and ambulatory function of the patient. If the fracture is
amenable to repair and TKA is well fixed, attempts are made to fix the fracture with
modern locked plates or intramedullary nail, whereas if implants are loose, consid-
eration should be given to DFR surgery. Preoperative planning of these surgeries is
central to ensuring the highest rate of success possible for the patients’ outcomes.
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2. Streubel PN, Ricci WM, Wong A, Gardner MJ. Mortality after distal femur fractures in elderly
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3. Rorabeck CH, Taylor JW. Classification of periprosthetic fractures complicating total knee
arthroplasty. Orthop Clin North Am. 1999;30(2):209–14.
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ties. Clin Orthop Relat Res. 2006;446:167–75.
5. Su ET, DeWal H, Di Cesare PE. Periprosthetic femoral fractures above total knee replace-
ments. J Am Acad Orthop Surg. 2004;12(1):12–20.
6. Culp RW, Schmidt RG, Hanks G, Mak A, Esterhai JL Jr, Heppenstall RB. Supracondylar
fracture of the femur following prosthetic knee arthroplasty. Clin Orthop Relat Res.
1987;222:212–22.
7. Merkel KD, Johnson EW Jr. Supracondylar fracture of the femur after total knee arthroplasty.
J Bone Joint Surg Am. 1986;68(1):29–43.
8. Streubel PN, Gardner MJ, Morshed S, Collinge CA, Gallagher B, Ricci WM. Are extreme
distal periprosthetic supracondylar fractures of the femur too distal to fix using a lateral locked
plate? J Bone Joint Surg Br. 2010;92(4):527–34.
9. Taljanovic MS, Hunter TB, Miller MD, Sheppard JE. Gallery of medical devices: part 1: ortho-
pedic devices for the extremities and pelvis. Radiographics. 2005;25(3):859–70.
10. Healy WL, Siliski JM, Incavo SJ. Operative treatment of distal femoral fractures proximal to
total knee replacements. J Bone Joint Surg Am. 1993;75(1):27–34.
11. Davison BL. Varus collapse of comminuted distal femur fractures after open reduction and
internal fixation with a lateral condylar buttress plate. Am J Orthop. 2003;32(1):27–30.
12. Figgie MP, Goldberg VM, Figgie HE 3rd, Sobel M. The results of treatment of supracondylar
fracture above total knee arthroplasty. J Arthroplast. 1990;5(3):267–76.
13. Ricci WM, Loftus T, Cox C, Borrelli J. Locked plates combined with minimally invasive inser-
tion technique for the treatment of periprosthetic supracondylar femur fractures above a total
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14. Norrish AR, Jibri ZA, Hopgood P. The LISS plate treatment of supracondylar fractures above
a total knee replacement: a case-control study. Acta Orthop Belg. 2009;75(5):642–8.
15. Kolb W, Guhlmann H, Windisch C, Marx F, Koller H, Kolb K. Fixation of periprosthetic femur
fractures above total knee arthroplasty with the less invasive stabilization system: a midterm
follow-up study. J Trauma. 2010;69(3):670–6.
16. Hoffmann MF, Jones CB, Sietsema DL, Koenig SJ, Tornetta P 3rd. Outcome of periprosthetic
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18. Raab GE, Davis CM 3rd. Early healing with locked condylar plating of periprosthetic fractures
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21. Falck M, Hontzasch T, Krettek C. LISS (less invasive stabilization system) als minimalinva-
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nailing and less invasive stabilization system in distal femoral fractures: a retrospective analy-
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26. Bong MR, Egol KA, Koval KJ, et al. Comparison of the LISS and a retrograde-inserted supra-
condylar intramedullary nail for fixation of a periprosthetic distal femur fracture proximal to a
total knee arthroplasty. J Arthroplast. 2002;17(7):876–81.
27. Herrera DA, Kregor PJ, Cole PA, Levy BA, Jonsson A, Zlowodzki M. Treatment of acute distal
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29. Srinivasan K, Macdonald DA, Tzioupis CC, Giannoudis PV. Role of long stem revision knee
prosthesis in periprosthetic and complex distal femoral fractures: a review of eight patients.
Injury. 2005;36(9):1094–102.
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knee arthroplasties. Clin Orthop Relat Res. 1990;252:182–9.
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prosthetic femoral fractures after total knee arthroplasty using a distal femoral allograft. J
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34. Saidi K, Ben-Lulu O, Tsuji M, Safir O, Gross AE, Backstein D. Supracondylar peripros-
thetic fractures of the knee in the elderly patients: a comparison of treatment using allograft-
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Arthroplast. 2014;29(1):110–4.
Chapter 8
Management of Periprosthetic Fractures
Around a Total Knee Arthroplasty
with a Loose Femoral Component
Michael Suk and Michael R. Rutter
Introduction
Periprosthetic distal femur fractures (PDFF) are complex problems for the surgeon
with the potential for significant complications. DiGioia et al. defined the area of a
supracondylar femur fracture following a total knee arthroplasty (TKA) as occur-
ring within 15 cm of the joint line or within 5 cm of the most proximal part of any
intramedullary component [1].
The incidence of PDFF has been reported to be between 0.3% and 2.5% [2–14].
This number is anticipated to rise with the increase use of prosthetic implants and
an aging population [2, 8]. The rate of PDFF following revision total knee arthro-
plasty (RTKA) is significantly higher, up to 38% [10, 14, 15]. Most PDFF are the
result of a low-energy trauma. Risk factors include osteopenia, osteoporosis, aseptic
or septic loosening, corticosteroid use, female gender, anterior femoral notching,
and neurologic disorders [1, 7, 9, 12, 13, 16].
The goal of treatment of PDFF is to provide the patient with a stable, painless
knee and to minimize malalignment [7]. The ultimate treatment depends on several
factors. Does the patient have adequate bone stock to support fixation? Is the pros-
thesis loose? Or is the patient healthy enough to undergo a major reconstruction
procedure? [6, 7, 12, 13]. Many of the patients in this population have significant
comorbidities, and fixation that does not allow for immediate weight-bearing can
have detrimental health effects as the patient will remain bedbound for a period of
time [14]. Here, in this chapter, we review the relevant points in treating a patient
with a periprosthetic fracture about a loose TKA component.
M. Suk
Musculoskeletal Institute, Geisinger Health System, Danville, PA, USA
e-mail: msuk@geisinger.edu
M. R. Rutter (*)
Department of Orthopedic Surgery, Geisinger Medical Center, Danville, PA, USA

https://doi.org/10.1007/978-3-319-43008-9_8
134 M. Suk and M. R. Rutter
Table 8.1 Neer and Type I Nondisplaced

associates’ fracture
Type II Displaced >1 cm
classification
Type IIa Displaced >1 cm with lateral femoral shaft
displacement
Type IIb Displaced >1 cm with medial femoral shaft
displacement
Type III Displaced and comminuted
Classification
Several fracture classifications have been created in an effort to guide treatment, as

described in the previous chapters. The Su classification (reviewed in Chap. 1) is
commonly cited. Neer and associates developed a classification system that consid-
ers fracture displacement about TKA (Table 8.1). The Lewis and Rorabeck classifi-
cation, also reviewed in Chap. 1, is arguably the most important as it assesses the
status of the component; is it loose or well-fixed? [7, 17, 18]. Proper assessment of
implant stability is the most important distinction because it determines whether to
proceed with open reduction and internal fixation or revision arthroplasty.
Patient Evaluation
Initial assessment of the patient should begin with a thorough discussion of his or
her TKA function prior to the fracture. Fractures around a well-fixed component
with no pre-injury pain do not require an infection work-up [12]. Pain (i.e., start-up
pain, “shin” pain) prior to injury should raise suspicion for a possible loose or
infected TKA [10, 12]. Any history of a draining wound and/or sinus is presumed
infected until proven otherwise. Regardless, laboratory exams including a complete
blood count with differential, C-reactive protein, erythrocyte sedimentation rate, as
well as a knee aspiration are required [12, 19]. Full-length femur films should be
obtained, and a CT scan may be useful to better understand the fracture pattern and
to assess loosening; if available, serial radiographs should be compared in prepara-
tion for any osteolytic defects that may impact implant stability and, therefore, lean
more quickly toward revision and/or DFR.
Operative Management
Historically, periprosthetic fractures were managed nonoperatively. Fixation and

revision arthroplasty were utilized as secondary procedures [10, 20]. Chen et al.
determined that displaced PDFF, Neer type II, have a significantly higher success rate
when treated with revision arthroplasty rather than ORIF [21]. There is consensus in
the literature that PDFF around a loose femoral component require a revision of at
8 Management of Periprosthetic Fractures Around a Total Knee Arthroplasty… 135
least the femoral component [2, 6, 7, 10, 12, 22]. A major advantage of revision sur-
gery is that it allows for early mobilization and a stable limb [2, 22]. Once the com-
ponent has been determined to be loose, implant selection is largely dependent upon
available metaphyseal bone stock. If there is sufficient metaphyseal bone available
once components are removed, traditional stemmed revision components may be
used. The most difficult scenarios arise when there is deficient metaphyseal bone
stock not allowing for the use of basic revision components [7]. For TKAs that require
revision, but have notable bony defects, the use of sleeves and cones can help achieve
restoration of the joint line and a stable revision TKA platform for weight-bearing.
eriprosthetic Fractures Treated with Standard Revision

P
Components: The Rare Exception
Typical location for a supracondylar fracture about a TKA femoral component often
centers around the metaphyseal–metal junction (flange), and inherent stability is
determined by bone quality that will or will not allow for fracture propagation dis-
tally. Here, intact medial and lateral condyles, attached to the femoral component,
are essential to overall determine if the implant is, indeed, “stable.” Similar to the
principles encountered in elective revision TKA, the determination to go to a hinged
component is determined by the integrity of the collateral ligaments, which in a
fracture can correlate to the medial and lateral condyles.
Thus, revision TKA in the setting of a periprosthetic fracture is often a rarity;
fractures often present with either intact or non-intact columns that indicate stability.
If the medial and lateral columns are maintained and the component remains well-
fixed, then fixation should occur; if the columns are compromised and there remains
no bone behind/attached to the femoral component, then revision (most often to a
DFR) should ensue. Revision TKA, reserved for the situation where the columns are
intact and revision is still needed, is rare. However, when performed, one should
adhere to the principles of revision: (a) remove the component with minimal bone
loss, (b) span the defect with cemented or cementless diaphyseal fitting stems if pos-
sible, and (c) ensure proper restoration of the joint line. The use of a stemmed revi-
sion component creates a stable construct, allowing patients to immediately weight
bear and begin range-of-motion exercises (Fig. 8.1a, b) [2, 7, 11]. Diaphyseal engag-
ing stems also provide stability to the fractures site [12, 20]. Osteopenia is common
among patients with PDFF, adding to the complexity of a revision case [2].
Cordeiro reported on ten patients who sustained fractures around a total knee.
Four of these were distal femur fractures treated with revision arthroplasty. The
authors concluded that patients treated with revision arthroplasty had superior
results based upon time of return to weight-bearing, range of motion, and mainte-
nance of anatomic alignment of the extremity [7, 20].
In a series of six PDFF, Srinivasan noted success when treating with long stem
revision components. All patients maintained satisfactory alignment and noted sig-
nificant improvement in visual analog pain scores. The main benefits of arthroplasty
as seen by the authors are stability and early range of motion [8].
a b
Fig. 8.1 (a, b) Revision TKA example; AP and lateral radiographs of a revision total knee using
diaphyseal engaging stemmed components. Note the use of the diaphyseal sleeve to help fill a bony
defect, along with medial column cement augmentation for restoration of the anatomic axis and
joint line
Periprosthetic Fractures Requiring Megaprosthetic Components
In the setting of significant bone loss, loosening, or comminution, traditional

stemmed components may not be a feasible option. The use of distal femoral
replacement (DFR) has emerged as an effective way to manage these complex frac-
tures. While these components have historically been used for oncologic recon-
struction, they have gained significant popularity for use in revision and trauma
settings. When reviewing 72 patients treated with megaprosthesis, 22 of whom sus-

tained PDFF with loose components. Calori et al. cited extensor mechanism restora-
tion, achieving correct limb length and rotation, skin coverage, and range of motion
of the implant as the main technical issues [23].
Mortazavi identified 18 knees with PDFF treated with DFR for an average of
59 months. In their cohort all patients had pain relief and stability with appropriate
range of motion. The complication rate, however, was not insignificant. Five patients
required additional surgeries for fractures around the stem of the component [6].
Haidukewych et al. presented 17 cases of TKA for salvage of failed internal
fixation or nonunion of distal femur fractures. Ten (59%) of these were treated
with a megaprosthesis. Results were not separated by type of implant used. The
5-year survivorship was 83%, and 1 case showed evidence of radiographic
loosening [24, 25].
Figure 8.2a–g demonstrates a case where a megaprosthesis was utilized. The
patient in this example is an 82-year-old female who sustained bilateral PDFF as a
result of a fall from standing. She was a community ambulator with no assistive
device. The index procedures were greater than 10 years ago. The fractures were
similar in location and pattern. The distal location of the fracture as well as loosen-
ing of the femoral component, determined from preoperative radiographs and con-
firmed during surgery, led to the decision to proceed with DFR. The preoperative
lateral (Fig. 8.2a) highlights a fracture of the posterior femoral condyle with dis-
placement from the prosthesis. The fracture can also be seen at the level of the
anterior flange, which ultimately required resection of the comminuted distal femur
and use of a DFR rather than standard revision components. Both extremities were
treated with an endoprosthesis. Figure 8.2h, i shows the postoperative radiographs.
At her 2-week follow-up, she was ambulating with minimal discomfort using a
rolling walker.
Use of Structural Grafts
Structural grafts may be utilized to provide support when there are large uncon-
tained defects [26]. These grafts can be in the form of metal augments, cement,
cortical allografts, and allograft prosthetic composites (APC) [26, 27]. This will
serve to provide a stable platform for fixation of implants. Structural allografts are
advantageous in that they maintain biocompatibility and can be shaped to fill the
host defect. However, they may fracture, increase surgical time, have increased sus-
ceptibility to infection, and can develop a nonunion [27]. Rates of nonunion have
been reported from 0% to 4% and infection from 0% to 10% [26, 27].
In a series of 68 revision knees that required structural allograft, Backstein et al.
identified an 85.2% survival rate at 5.4 years. In 4.9% of these cases, revision was
required secondary to infection and 11.5% necessitated a revision for allograft com-
plication [26].
a b c
d e f
g h i
Fig. 8.2 An 82-year-old female who sustained bilateral PDFF as a result of a fall from standing.
The preoperative lateral (a) highlights a fracture of the posterior femoral condyle with displace-
ment from the prosthesis, noting implant instability. The fracture can also be seen at the level of the
anterior flange, which ultimately required resection of the comminuted distal femur and use of a
DFR rather than standard revision components. Both extremities were treated with an endopros-
thesis, shown in the fluoroscopic images (b–g); (h, i) shows the postoperative radiographs
Similarly, a 75.9% survival at 10 years was seen by Bauman et al. Half of the 16
failures were due to graft failure. One was the result of a host–allograft nonunion
and the other seven were secondary to resorption. Average time to failure was
44.1 months. They were able to conclude that the use of small allografts was more
likely to fail due to resorption resulting in loosening whereas larger grafts were
more likely to fail due to nonunion or infection [27].
An allograft prosthetic composite (APC) is a less frequently utilized tool for

dealing with PDFF. With this technique, a distal femur allograft is appropriately
sized and fixed to the implant on the back table (Fig. 8.3). The implant stem is then
press fit into the host bone and collateral ligaments reattached [26]. Wong highlights
the importance of stabilizing the host–graft junction by creating a step cut or oblique
osteotomy and wrapping the host bone around the graft. In five patients who were
treated with an APC for PDFF, one experienced an asymptomatic nonunion and a
second required conversion to a hinged prosthesis due to joint instability [28].
Plate fixation supplemented with a strut allograft, either intra- or extramedullary,
is another alternative for fixation of PDFF. Virolainen et al. identified 20 PDFF that
were managed utilizing an extramedullary graft. Eighty-five percent showed bony
union, while two developed and infection and one went on to a malunion [29]. In a
series by Kumar et al., three fractures were treated using an intramedullary fibular
strut with adjunctive plate fixation. All of these were healed with no postoperative
complications. The use of the strut for distal fractures with metaphyseal comminu-
tion provided four cortices and alleviated the need for locking plates [16].
Conclusions
It is the preferred technique of the authors to use a distal femoral replacement for
several reasons. First, this provides a mechanically stable joint that does not rely
upon ligament healing to allograft to impart stability. Secondly, there is no risk of
nonunion between the host femur and graft [28]. Third, use of an APC introduces a
potential source for infection to the reconstruction. Floren et al. noted a 6.9% infec-
tion rate following allogenic bone transplantation procedures [30].
a b
Fig. 8.3 (a) Lateral and (b) AP view of a sawbones model of a distal femur allograft prosthetic
composite
While periprosthetic distal femur fractures continue to be a challenging problem

for orthopedic surgeons, there are various fixation techniques for the surgeon to
utilize. When properly managed, most patients who have sustained these injuries
will regain a stabile knee, allowing them to weight bear. Patient factors such as bone
quality, location of fracture, type of implant, and medical comorbidities should all
be considered when selecting the most appropriate fixation for PDFF. Our preferred
method is to utilize DFR (especially in the elderly), as it is a facile, efficient proce-
dure that allows for immediate weight-bearing.
References
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implant composites, standard revision components, distal femoral replacement prosthesis. J
Arthroplast. 2014;29(1):110–4.
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Orthop Traumatol. 2010;11(3):135–41.
8. Srinivasan K, Macdonald DA, Tzioupis CC, Giannoudis PV. Role of long stem revision knee
prosthesis in periprosthetic and complex distal femoral fractures: a review of eight patients.
Injury. 2005;36(9):1094–102.
9. Kassab M, Zalzal P, Azores GM, Pressman A, Liberman B, Gross AE. Management of peri-
prosthetic femoral fractures after total knee arthroplasty using a distal femoral allograft. J
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10. Johnston AT, Tsiridis E, Eyres KS, Toms AD. Periprosthetic fractures in the distal femur fol-
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total knee arthroplasty. J Knee Surg. 2003;16(2):111–7.
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femur fractures following total knee arthroplasty. J Arthroplast. 2004;19(4):453–8.
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Wilkins; 2003.
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arthroplasty. Orthop Clin N Am. 1999;30(2):209–14.
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sion total knee arthroplasty. J Bone Joint Surg Am. 2007;89(7):1409–16.
20. Cordeiro EN, Costa RC, Carazzato JG, Silva JD. Periprosthetic fractures in patients with total
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ments. J Am Acad Orthop Surg. 2004;12(1):12–20.
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traumatic and periprosthetic large bone defects: issues to consider. Injury. 2014;45:S105–10.
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useful in complex total knee arthroplasty revisions. Clin Orthop Relat Res. 2006;446:113–20.
25. Haidukewych GJ, Springer BD, Jacofsky DJ, Berry DJ. Total knee arthroplasty for salvage of
failed internal fixation or nonunion of the distal femur. J Arthroplast. 2005;20(3):344–9.
26. Backstein D, Safir O, Gross A. Management of bone loss: structural grafts in revision total
27. Bauman RD, Lewallen DG, Hanssen AD. Limitations of structural allograft in revision total
knee arthroplasty. Clin Orthop Relat Res. 2009;467(3):818–24.
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the hip and knee. Orthop Clin N Am. 1999;30(2):259–64.
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Tissue Bank. 2010;11(3):253–9.
Chapter 9
Periprosthetic Fractures Around
a Total Knee Arthroplasty with a Stable
and Loose Tibial Component
Jeff R. Petrie, Adam A. Sassoon, and George J. Haidukewych
Introduction
As an effective surgery to decrease pain and improve function in patients with end-
stage arthritis of the knee, total knee arthroplasty performance is sharply increasing
in the United States [1]. Associated with this growth, inevitably, comes an increase
in complications [1]. Periprosthetic fractures about TKA occur infrequently; how-
ever, as the population with total knee implants ages, continues to be active, and
develops decreased bone mineral density, the rate of these injuries will rise [2–4].
While the literature is expansive in regard to the treatment of these injuries involv-
ing the femur, there is an astonishing deficiency in high-level studies directing sur-
geons for the optimal treatment of periprosthetic fractures of the tibia [5–9]. These
injuries can be devastating, especially in the elderly, physiologically compromised
patients in which they usually occur. Surgeons caring for these individuals should
have experience in fracture care as well as arthroplasty, and our goal is to provide
some treatment solutions for the surgeon faced with treating periprosthetic tibia
fractures.
J. R. Petrie · G. J. Haidukewych (*)

Division of Orthopedic Trauma and Complex Adult Reconstruction,
Department of Orthopedic Surgery, Orlando Regional Medical Center,
Orlando, FL, USA
e-mail: George.haidukewych@orlandohealth.com
A. A. Sassoon
Department of Orthopedics and Sports Medicine, Northwest Hospital
University of Washington, Seattle, WA, USA

https://doi.org/10.1007/978-3-319-43008-9_9
144 J. R. Petrie et al.
Incidence and Risk Factors
Periprosthetic fractures of the tibia associated with TKA can occur intraoperatively
or postoperatively and are a devastating and challenging complication to both
patient and surgeon. Though increasing, the literature reports tibial periprosthetic
fractures occurring in 0.4–1.7% of patients undergoing TKA [3, 10–12]. The largest
series to date comes from the Mayo Clinic, which looked at 17,727 TKAs. They
described intraoperative fractures occurring in revision surgery five times more
prevalent (0.36% versus 0.07%) than in primary TKA, although the rate of postop-
erative tibial fracture after primary and revision surgery was more similar (0.39%
and 0.48%, respectively) [12]. The same authors conveyed an average time to post-
operative tibial fracture of 60 months, and twice as many females suffered these
fractures compared to males [12]. Additionally, Alden et al. found an intraoperative
fracture rate of 0.4% in primary TKA, with only 27% involving the tibia and the
remainder occurring on the femoral side [13]. Three quarters of the intraoperative
fractures in this series occurred during exposure and/or bone preparation and com-
ponent trialing [13].
Numerous risk factors for periprosthetic tibia fractures are known and can be
grouped into patient-related factors or local factors inherent to surgical technique
and/or implant design (Table 9.1). Certain patient qualities, including osteoporosis/
osteopenia as well as those with metabolic disease of bone (osteomalacia, Paget’s
disease, osteogenesis imperfecta, osteopetrosis) place them at risk for any peripros-
thetic fracture, not solely those of the tibia [10]. Additionally, patients on chronic
corticosteroids for lung conditions (asthma, COPD), psoriatic arthritis, and espe-
cially rheumatoid arthritis should be considered at heightened risk [10, 14–16].
Individuals with neurological disease are also vulnerable secondary to difficulty
with gait and the subsequent threat of falls. Concern should be raised in patients
with previous hardware in the knee, as screw holes can represent stress risers, and
also in patients with severe preoperative deformity or contractures [10, 15, 17].
Inappropriate surgical technique and certain design features can also influence
the risk of fracture. In a small series by Ritter et al., 22% of patients sustained a
tibial shaft fracture after undergoing tibial tubercle osteotomy, though all were
Table 9.1 Risk factors for periprosthetic tibia fractures in TKA

Patient factors Surgical factors Implant design
Osteoporosis Tibial tubercle osteotomy Keeled tibia
Rheumatoid arthritis Aggressive tibial component Peg or finned tibia
impaction
Neurologic disease Varus/rotational malalignment Intramedullary
referencing
Metabolic bone disease (i.e., Cement removal Press-fit tibial stems
osteomalacia)
Preop knee alignment (neutral or Aggressive retraction Long tibial stems
valgus)
9 Periprosthetic Fractures Around a Total Knee Arthroplasty with a Stable and Loose… 145
successfully treated nonoperatively [18]. Furthermore, component malalignment,

forceful trial reductions, aggressive manipulation under anesthesia, and knee insta-
bility are contributing factors for fracture in primary TKA [12, 13, 19–21]. In the
revision setting, osteolysis or poor quality bone can lead to fracture when removing
cement, impacting components, or extracting well-fixed components [12].
lassification of Periprosthetic Tibia Fractures

C
and General Treatment
Classification systems in orthopedics allow for accurate communication among

surgeons and aid in developing algorithms for the swift diagnosis and subsequent
treatment of various fractures. The Unified Classification System (UCS), based on
the Vancouver classification for periprosthetic femoral fractures, is a validated and
recent system devised for any periprosthetic fracture, although few studies have
described its use in periprosthetic fractures of the tibia [5, 22]. The most widely
used in regard to periprosthetic tibial fractures is the Mayo classification developed
by Felix, Stuart, and Hanssen (Fig. 9.1) [10, 12, 23]. This system uses three charac-
teristics to describe the fracture type in question: fracture location as it relates to the
implant, timing (intraoperative versus postoperative), and implant stability.
Type I
Type IV
Type II
Type III
Anteroposterior Lateral
Fig. 9.1 Anteroposterior and lateral illustrations of four-part Mayo fracture classification of peri-
prosthetic tibial fractures. (From Hanssen et al. [29], with permission from Springer)
Type I Fractures
First, fractures are categorized by their location relative to the implant. Type I frac-
tures occur in the tibial plateau as a split or depression extending to the bone-implant
interface [12]. These are the most common periprosthetic tibial fracture, often
involve the medial plateau, and have been associated with cementless TKA compo-
nents [10, 12]. Out of 102 periprosthetic tibial fractures, Felix et al. found 61 (60%)
Type I fractures, and of these 55 (90%) involved the medial plateau [12]. Additionally,
the majority of these Type I fractures were associated with a loose tibial component,
and they are frequently found with concomitant varus malalignment of the tibia in
the index TKA [12, 20]. Type IA fractures are associated with a well-fixed implant
and are exceedingly uncommon [12]. Their treatment consists of nonoperative man-
agement with protected weightbearing and range of motion. On the other hand, Type
IB fractures involve a loose tibial component resulting from osteolysis from tibial
component fracture or progressive malalignment. Typically, combined cavitary and
segmental bone defects are present and necessitate revision surgery [10, 21, 23].
Studies that have tried nonoperative treatment for IB fractures have noted the inevi-
table requirement for revision surgery [12, 20]. Felix and associates attempted cast-
ing and bracing on 17 of 23 Type IB fractures, and all 17 underwent revision surgery
by 2 years [12]. Likewise, in 15 Type IB fractures occurring in geometric and poly-
centric knees, Rand and Coventry reported that all 15 required revision surgery [20].
Type IC fractures involve the tibial plateau and occur intraoperatively, though
they may not be noted until postoperative radiographs are obtained. Removal of
well-fixed components, insertion of keeled (or pegged/finned) implants, cement
removal with osteotomes, and forceful trial reduction can cause these fractures. The
majority of Type IC fractures are nondisplaced and can be appropriately managed
with protected weightbearing while allowing knee range of motion. If displacement
is noted intraoperatively, anatomic reduction with screw fixation can be performed
with subsequent insertion of the final implant. Alternatively, minor defects can be
filled with cement or bone graft, or conversion to a stemmed implant that serves to
bypass the fracture can be successful [12, 23].
Type II Fractures
The second most common periprosthetic fracture of the tibia is the Type II injury,
which occurs at the metadiaphyseal junction of the tibia adjacent to the implant’s
stem [12]. Type IIA fractures commonly involve a traumatic event and regularly are
minimally displaced. If axial alignment can be maintained, these fractures can be
treated with cast immobilization and protected weightbearing [12, 23]. Type IIA
fractures with displacement are treated based on the fracture characteristics, but
generally every attempt to preserve the well-fixed component is made. Closed
reduction and casting can be attempted, and if in vain, open treatment by traditional
fixation principles is warranted.
Type IIB injuries often have extensive osteolysis and occur in patients with loose,
stemmed tibial components. The extensive osteolytic lesions make these injuries
challenging to treat, as they can have large cavitary deficiencies and segmental
defects at the metadiaphysis [23]. Efforts at nonoperative treatment only delay the
inevitable need for revision, thus it is recommended to revise these injuries utilizing
structural or morselized bone grafting and long tibial stems that bypass the defects
[10, 12].
Type IIC fractures occur intraoperatively, often transpiring when utilizing long,
stemmed tibial implants, although they can also be made with reamers or cement
removal tools. Generally, these injuries are minimally displaced, vertically oriented
fractures that are noticed on postoperative radiographs [24]. In this case, protected
weightbearing and a hinged knee brace will often allow for healing as minimal peri-
osteal disruption has occurred. Recognition of a Type IIC fracture intraoperatively
requires fracture assessment and decision making for potential plate fixation and
utilizing a longer tibial stem to bypass the fracture.
Type III Fractures
Only 17% of periprosthetic tibia fractures in the study by Felix et al. were catego-
rized as Type III [12]. These injuries occur in the tibial shaft distal to the prosthesis,
and the majority are found with well-fixed components, thus revision arthroplasty is
rarely required [12, 23]. Type III fractures are reported to occur either traumatically
or secondary to stress from limb malalignment or after tibial tubercle osteotomy
[18, 23, 25]. When a loose prosthesis is encountered with a fracture distal to the
prosthesis (Type IIIB), a treatment plan should be tailored to the individual patient.
These injuries are exceedingly rare, but treatment involves either acute revision
combined with fracture stabilization or staged treatment with fracture healing (cast
immobilization or open reduction and internal fixation) accomplished prior to revi-
sion arthroplasty.
Type IV Fractures
Also rare, Type IV periprosthetic tibia fractures are those which involve the tibial
tubercle [12]. These injuries can be devastating as they can involve disruption of
the extensor mechanism. In their review of periprosthetic tibia fractures, Felix
et al. had only 2 of 102 fractures that were Type IV [12]. Both occurred after a fall
and had well-fixed implants. Nonoperative treatment via immobilization in exten-
sion is reserved for patients who maintain active extension and have minimal dis-
placement of the fracture. Alternatively, for displaced injuries, restoration of
extensor function can be achieved through screw fixation or tension band tech-
niques [26, 27].
Authors’ Preferred Treatment Strategies
As the majority of periprosthetic fractures around total knee implants involve the
femur, there is a paucity of literature concerning the treatment of these difficult
injuries when involving the tibia [3, 10, 12, 20, 21, 23, 28]. Useful treatment algo-
rithms for periprosthetic tibia fractures have been suggested in the past (Fig. 9.2),
but the surgeon must treat each patient individually and thoroughly evaluate the
injury preoperatively for their successful management [29]. Specifically, treatment
is based on the fixation status of the tibial component, fracture location, and the
remaining bone stock [12, 20]. We prefer to salvage well-fixed components if at all
possible through standard open reduction and internal fixation techniques; however,
loose components force one’s hand for revision arthroplasty.
Well-Fixed Components
A variety of locked plating techniques can be utilized for periprosthetic tibia frac-
tures with stable TKA components. Typically, in Type IIA injuries involving the
metadiaphysis, a lateral-based approach is employed, with special attention focused
on preserving the soft tissue envelope (Fig. 9.3a–f). Modern locked plating systems
allow for sufficient bony fixation in these injuries in which host bone is often mar-
ginal, and we almost exclusively use them in these situations. Additionally, as these
fractures often occur secondary to trauma, computed tomography can aid in defin-
ing the fracture pattern and is invaluable when devising an operative plan.
In periprosthetic tibia fractures occurring distal to a well-fixed tibial implant
(Type IIIA), either plating or intramedullary nailing can achieve satisfactory fixa-
tion. If plating is preferred, often a percutaneous medial approach is utilized to span
the tibia and limit additional soft tissue trauma (Fig. 9.4a–j). A plate of sufficient
length is chosen prior to incision and slid up the tibia through a 3–4 cm distal inci-
sion. Indirect fracture reduction techniques are employed, and metaphyseal com-
minution can be spanned. The plate should overlap intramedullary tibial stems,
gaining purchase through bicortical or unicortical screws [30].
In patients with Type IIIA fractures whose components allow, intramedullary
nailing has also been performed with success at our center (Fig. 9.5a–f), though to
Major anatomic pattern Subcategory
I: Tibial plateau A: Prosthesis well-fixed

II: Adjacent to stem B: Loose prosthesis Fracture type
III: Distal to prosthesis C: Intraoperative
IV: Tibial tubercle
Fig. 9.2 The specific fracture type is obtained by combining one of the four major fracture pat-
terns with one of the three subtypes. (From Hanssen et al. [29], with permission from Springer)
a b c
d e f
Fig. 9.3 A 60-year-old male was involved in a motor vehicle collision and sustained a Type IIA
periprosthetic tibia fracture, which included a nondisplaced tibial tubercle injury (a, b). A CT scan
with coronal and sagittal imaging (c, d) was obtained for preoperative planning, and the tibial
implant was well-fixed. Final anteroposterior and lateral operative films (e, f) show lateral-based
fixation with a locking plate and a supplemental anterior plate for rigid fixation of the tibial tuber-
cle fracture
our knowledge, there is no data yet supporting this. Here, the previous TKA incision
is exploited to find a starting point distal to the tibial tray that will not alter its
cement fixation. Fluoroscopic images are scrutinized in numerous planes to ensure
an adequate start point and to take care not to injure the tibial tubercle during nail
insertion. Interlocking screws are then added for length stable fixation, and patients
are able to weight bear with assistance postoperatively.
a b c
d e f
Fig. 9.4 An elderly female with a revision TKA suffered a ground-level fall and sustained a Type
IIIA periprosthetic tibia fracture (a). Percutaneous locking fixation was chosen, and prior to drap-
ing, the planned plate was imaged to ensure proper overlap with the tibial implant (b–d). A medial
incision (e) was utilized, and the plate was maneuvered submuscularly onto the medial tibia (f) and
provisionally fixed (g). Percutaneous fixation in this manner allows for an indirect reduction with
optimal respect for the soft tissue envelope (h). Final postoperative anteroposterior (i) and lateral
(j) images of the construct with spanning of the metaphyseal comminution and multiple locking
screws obtaining fixation anterior to the tibial stem
g h i j
Fig. 9.4 (continued)
Loose Components
If components are loose or if appropriate alignment cannot be achieved by fracture

fixation methods, the arthroplasty must be revised. The surgeon should anticipate
the need to revise the femoral side as well, and it is wise to have augments, sleeves,
cones, and/or hinge components available should the need arise. These cases can be
exceedingly difficult, thus one should have sound experience with complex knee
reconstruction and fracture management to direct acceptable patient outcomes.
General principles of revision knee arthroplasty should be considered and include:
1 . Creation of a stable tibial platform
2. Achieving neutral alignment
3. Avoiding tibial overhang
4. Utilizing stems to bypass bony defects
5. Managing bony defects with augments, cones, and sleeves
Type IB fractures are most commonly encountered and involve the medial pla-
teau and occur due to varus malalignment and loosening. More straightforward
bony deficiencies can be effectively managed with revision arthroplasty utilizing
tibial stems and augments to support the final construct (Fig. 9.6a–d). However,
severe proximal tibial bone destruction can require a combination of modular metal
augments, cement, bone grafting, or even custom tumor prostheses (Fig. 9.7a–g).
a b
Fig. 9.5 Anteroposterior (a) and lateral (b) radiographs of a 76-year-old female with diabetes who
fell and sustained a Type IIIA periprosthetic tibia fracture. To minimize trauma to the soft tissues,
intramedullary nailing was chosen for fixation, and care was exercised to scrutinize the start point
(c) for nail insertion (d) to avoid damage to the extensor mechanism. Postoperatively, the patient
was allowed full weightbearing, and healing is noted at 8 weeks follow-up (e, f)
e f
Fig. 9.5 (continued)
Summary
Even though uncommon, when they do arise, periprosthetic fractures of the tibia
pose potentially devastating problems for patient and surgeon alike. Surgeons treat-
ing these injuries should be astute to techniques in fracture fixation as well as revi-
sion arthroplasty, and alternative treatment plans may need to be employed
intraoperatively secondary to the severe osteopenia and bone defects often encoun-
tered. Determination of whether components are loose or well-fixed is paramount in
devising a treatment plan: fixation versus revision arthroplasty. Whether utilizing
plates, intramedullary nails, or revision TKA techniques, the goal is to return the
patient to pre-fracture status as soon as possible.
a b c
Fig. 9.6 Anteroposterior (a) and lateral radiographs (b) of a 64-year-old male with a primary total
knee arthroplasty performed 4 years earlier. He noted progressive pain and “bowing” of his leg
over the last 6 months and had a large anteromedial bony deficiency in the tibial plateau.
Postoperative radiographs (c, d) with revision total knee replacement with a medial tibial augment
and tibial stem bypassing the bony defect
a b c
d e
f g
Fig. 9.7 Anteroposterior (a) and lateral (b) radiographs of a 65-year-old female with Charcot
arthropathy-associated catastrophic failure of a total knee arthroplasty with chronic dislocation and
associated Type IB periprosthetic tibia fracture. Intraoperatively (c) she was found to have signifi-
cant bone stock deficiencies of the tibia requiring trabecular metal metaphyseal cone augments that
were unitized prior to implantation (d). The final intraoperative (e) and postoperative images (f, g)
show conversion to a hinged implant with long tibial stems and cement fill
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Index
A B
Acetabular bone loss, 36 Baba classification, periprosthetic fractures, 7
Acetabular fracture Bone scan, 12
anterior approach, 26–32
classification systems, 38–41
complications, 47 C
diagnosis, 38 Cable grip system, 111–112
etiology, 36–38 Callaghan classification,
incidence, 36 intraoperative fractures, 39
intraoperative (see Intraoperative Cementless stems, hip fracture, 74
acetabular fracture) Cerclage fixation, 110
Kocher-Langnbeck approach, 24–26 Charlson Comorbidity Index, 55
management, 41–43 Cierny and Mader’s classification,
outcomes of surgical periprosthetic fractures, 10–11
treatment, 47–49 Cobb elevator, 22
Acetabular loosening, 37, 44 Cortical strut allografts, 88, 90
AKA tumor prosthesis, distal femur
fracture, 65–69
Allograft prosthesis composites D
(APC), 90, 91 Della Valle classification, acetabular
periprosthetic distal femur fracture, 38–40
fractures, 139 Deyo–Charlson index, 4
revisions systems, 65 Diaphyseal fitting stem, 83, 86
Allograft strut, 116 Distal femur fractures, 54–58
Alpha-defensin, 14 case presentations, 67
Anterior Smith-Peterson approach classifications, 55
ASIS osteotomy, 27 elderly patients, 55
description, 27 internal fixation, 55
incision and capsulotomy, 27 intramedullary fixation, 61
patient positioning, 27 locked plating technology, 60
pelvic reconstruction plate, 29 non-operative treatment, 57
postoperative care, 32 open reduction and internal fixation, 59
AO/OTA classification system, operative treatment, 57
periprosthetic fractures, 8 revision total knee arthoplasty, 63–64
Atypical femur fractures (AFFs), 11 tips and tricks in surgical techniques, 67

https://doi.org/10.1007/978-3-319-43008-9
160 Index
E displaced posterior column

Extended trochanteric osteotomy (ETO), 79 component, 23–24
nondisplaced posterior column
component, 22–23
F
Felix classification, periprosthetic fractures, 8
Femoral fracture K
femoral stress, 100 Kocher-Langenback approach, 24
fixation with stable implants, 100 acetabular implant, 26
IMN implants, 101 arthroplasty, 25
interpositional femoral device, 101 fracture fixation, 24
LISS plating, 100 patient positioning, 24
Femoral stress, 100 postoperative care, 26
Fixation method for distal femur
fractures, 57
L
Lateral locked plating, 115, 128–129
G Letournel transtectal transverse
Goldberg classification of periprosthetic acetabular fracture, 21
tibial fractures, 8 Linked fixation, 103
LISS system, 61–63
Locked plating
H distal femur fracture, 61
Harris hip score, 91 tibia fracture, 148
Hip fracture
implant selection, 86–90
intraoperative tips and tricks, 79–85 M
patient evaluation, 75 Mayo classification, tibial fracture, 145
plate fixation, 85 Megaprosthesis, 92
pre-operative plan, 79 Metagenomic sequencing, 14
radiographic evaluation, 76 Metaphyseal fracture reduction, 128
risk factors, 74–75 Minimally invasive plate osteosynthesis
treatment goals, 79 (MIPO), 117
Vancouver Classification, 76 Modified Vancouver classification,
Hybrid plating, 120–129 acetabular fracture, 39
Hydroxyapatite (HA) coating, 89 Mulay’s technique, 79
Hypovitaminosis D, 67–68
N
I Nail-plate combo fixation (NPC), 103–104
Impaction grafting, 90 Non-operative treatment, distal femur
Interimplant fractures, 100 fractures, 57
Interlocking fixation, 103
Interprosthetic fracture fixation
case presentation, 102–105 O
femoral fracture, 100–101 Open reduction and internal fixation (ORIF)
Intramedullary fixation, distal femur acetabular fracture, 43
fracture, 61–62 distal femur fracture, 58–65
Intramedullary nailing ORIF and THA for acetabular fractures
retrograde, 68 anterior approach, 26–32
tecnique of, 68 complications, 32
tibia fracture, 148 Kocher-Langnbeck approach, 24
Intraoperative acetabular Osteolysis, 109, 111–112
fracture, 21–22 Osteopenia, 5
Index 161
P Supracondylar femur fractures, 55

Paprosky classification, acetabular Synovasure test, 14
fracture, 40–41
Patella fractures, 8
Periprosthetic atypical femoral T
fractures (PAFFs), 11 Tibia fracture
Periprosthetic distal femur fractures (PDFF) classification and general treatment,
classifications, 134 144–147
incidence, 133 incidence and risk factors, 144–145
megaprosthetic components, 136–137 treatment for loose components, 151–153
operative management, 134–139 treatment for well-fixed components,
patient evaluation, 134 148–151
structural grafts, 137 Tibial tubercle osteotomy, 144
treatment with standard revision Total knee arthroplasty (TKA)
components, 135 distal femur fracture, 54
Periprosthetic fractures, 3 revision, distal femur fracture, 65
acetabular fracture management ( see tibia fracture ( see Tibia fracture)
Acetabular fracture) Trochanteric claw plates, 112
below the level of femoral Type I periprosthetic tibial fractures, 146
component, 117 Type II periprosthetic tibial
classification, 5–10 fractures, 146–147
diagnostic studies, 5 Type III periprosthetic tibial fractures, 147
evaluation/diagnosis, 10–11 Type IV periprosthetic tibial fractures, 147
femur at the level of stem, 113
in elderly patients, 4
of greater trochanter, 109 V
and joint infection, 12–15 Vancouver A fracture
of tibia ( see Tibia fracture) incidence, 109
risk factors, 4 patient positioning and approach, 110
Periprosthetic joint infection, 12 preoperative planning, 109
Periprosthetic osteolysis, 5 surgical fixation, 110
Plate fixation, 79–86 tips and tricks in surgical fixation, 112
Prophylactic cable, 83 Vancouver B fracture
Prosthetic replacement procedures, 5 minimally invasive isolateral lateral
Proximal femoral replacement (PFR), 92 locking plate fixation, 116
open reduction and internal fixation, 113
operative technique, 116
R patient positioning and approach, 113–116
Reaming techniques, 25 preoperative planning, 113
Revision hip arthroplasty, 40, 41 tips and tricks in surgical fixation, 117–119
Revision total knee arthroplasty, 63 Vancouver C fracture, 117
Rorabeck classification system, patient positioning and approach,
periprosthetic fractures, 8 117–120
preoperative planning, 119
singular lateral plate fixation, 120
S tips and tricks, surgical fixation, 127
Structural grafts, 137–139 Vancouver classification, periprosthetic
Subtectal transverse acetabular fracture, 21 fractures, 5–7

Periprosthetic FRACTURES

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What is the book about?

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What classifications are used for periprosthetic fractures?

What classifications are used for periprosthetic fractures?

Periprosthetic

Surgical Techniques and Tips

ISBN 978-3-319-43007-2 ISBN 978-3-319-43008-9 (eBook)

Library of Congress Control Number: 2018960890

© Springer Nature Switzerland AG 2019

Jersey City, NJ, USA Frank A. Liporace, MD

Part I Before the Surgery

Part II Periprosthetic Fractures About the Hip

Part III Interprosthetic, Interimplant and Periprosthetic

8 Management of Periprosthetic Fractures Around a Total Knee

Frank A. Liporace, MD Division of Orthopedic Trauma and Adult Reconstruction,