What is the recommended approach for reducing a periprosthetic femur fracture with hip dislocation in the Emergency Department (ED)?

Management of Periprosthetic Femur Fracture with Hip Dislocation in the Emergency Department

Periprosthetic femur fractures with hip dislocation in the Emergency Department should NOT undergo closed reduction attempts and require urgent orthopedic consultation for operative management. 1

Initial Assessment and Management

Pain Management

• Implement multimodal analgesia immediately:
  • Administer regular paracetamol 2
  • Consider peripheral nerve blockade (femoral nerve or fascia iliaca block) - strong evidence supports this approach 2
  • Avoid NSAIDs in elderly patients or those with renal dysfunction 2
  • Use opioids cautiously with reduced dosing in patients with renal dysfunction 2
  • Avoid codeine due to constipation, emetic effects, and association with cognitive dysfunction 2

Imaging

• Obtain AP pelvis and lateral hip radiographs to:
  • Assess fracture pattern and location
  • Determine prosthesis stability
  • Evaluate bone quality 1
  • Classify according to Vancouver classification system 1, 3

Pre-operative Care

• Do NOT attempt closed reduction in the ED for periprosthetic fractures with dislocation 1
• Do NOT apply preoperative traction (strong evidence against this practice) 2
• Ensure adequate hydration before surgery 2
• Administer prophylactic antibiotics according to hospital protocol 2
• Consider thromboprophylaxis with low molecular weight heparin 2

Operative Management Considerations

Anesthesia

• Either spinal or general anesthesia is appropriate (strong evidence) 2
• For spinal anesthesia:
  • Use lower doses of intrathecal bupivacaine (<10 mg) to reduce hypotension 2
  • Consider intrathecal fentanyl for postoperative analgesia 2
• For general anesthesia:
  • Use reduced doses of induction agents 2
  • Consider higher inspired oxygen concentrations 2

Surgical Approach

• Surgical strategy depends on:

  • Fracture location
  • Prosthesis stability
  • Bone quality 1, 3

• For stable implants:

  • Open reduction and internal fixation with plates, cables, or strut grafts 4

• For loose implants or poor bone stock:

  • Revision arthroplasty with longer stem bypassing the fracture by at least two femoral diameters 4
  • Consider proximal femoral replacement for severe bone deficiency (Vancouver type B3) 5

Intraoperative Considerations

• Administer tranexamic acid to reduce blood loss (strong evidence) 2
• For cemented components:
  • Surgeon should verbally alert the anesthesiologist before cement application 2
  • Anesthesiologist should increase oxygen concentration during cementation 2
  • Maintain adequate hydration and blood pressure 2
  • Be prepared for bone cement implantation syndrome (BCIS) with vasopressors readily available 2

Post-operative Management

Immediate Care

• Allow weight-bearing as tolerated in most cases 2
• Monitor for symptomatic anemia:
  • Transfuse for symptomatic anemia 2
  • Maintain transfusion threshold no higher than 8 g/dL in asymptomatic patients 2
• Continue VTE prophylaxis with sequential compression devices and pharmacological agents 2

Monitoring

• Watch for complications:
  • Dislocation (particularly common in proximal femoral replacements) 5
  • Infection/wound drainage 5
  • Re-fracture distal to the stem 5
  • Implant failure 5

Common Pitfalls and Caveats

• Do not attempt closed reduction of periprosthetic fractures with dislocation in the ED as this may worsen the fracture or cause neurovascular injury 1
• Avoid excessive manipulation of the affected limb prior to surgery 2
• Do not delay surgical intervention as this increases morbidity and mortality 2
• Be vigilant for BCIS during cemented procedures, especially in elderly patients 2
• Consider bone quality when planning surgical approach - poor bone stock may require more extensive reconstruction 4, 3
• Test hip stability intraoperatively if proximal femoral replacement is used and consider constrained liners if instability is encountered 5

By following this algorithmic approach to periprosthetic femur fractures with hip dislocation, emergency physicians can optimize initial management while preparing the patient for definitive surgical treatment.