What is the management of periprosthetic fractures adjacent to the femoral (femoral bone) stem?

From the Guidelines

Management of prosthetic fractures adjacent to the femoral stem requires a tailored approach based on fracture location, implant stability, and bone quality, with the most recent evidence from 2022 suggesting the use of cemented femoral stems in arthroplasty for the treatment of hip fractures in older adults 1.

Key Considerations

• Initial treatment should include immediate non-weight bearing status and orthopedic consultation.
• For stable implants with minimally displaced fractures, conservative management with protected weight bearing for 6-12 weeks may be sufficient.
• However, most cases require surgical intervention, with the Vancouver classification guiding treatment:
  • Type A fractures (trochanteric region) typically need cable fixation or plate-and-screw constructs.
  • Type B1 fractures (around stem with stable implant) require open reduction and internal fixation with plates and cerclage wires while maintaining the original prosthesis.
  • Type B2 and B3 fractures (loose stem or poor bone stock) necessitate revision arthroplasty with a longer stem to bypass the fracture site, often with structural allograft for B3 cases.
  • Type C fractures (distal to stem) are treated with standard fracture fixation techniques.

Postoperative Care

• Patients typically remain non-weight bearing for 6-8 weeks, followed by progressive weight bearing as healing progresses.
• Calcium (1200mg daily) and vitamin D (800-1000 IU daily) supplementation is recommended, and osteoporosis treatment with bisphosphonates may be indicated after fracture healing.

Importance of Proper Classification and Surgical Planning

• These fractures are challenging complications with high morbidity rates, occurring due to stress risers at the prosthesis tip, osteolysis, or trauma.
• Proper classification and appropriate surgical planning are essential for successful outcomes, as highlighted by the 2020 study on the pathogenesis and management of fracture-related infection 1.

Imaging and Follow-up

• Radiographs are an integral part of the workup for suspected periprosthetic infection, but are neither sensitive nor specific for diagnosing infection, as noted in the 2023 study on ACR appropriateness criteria for imaging after total knee arthroplasty 1.
• Serial follow-up radiographs are important for identifying postoperative complications related to loosening and for monitoring fracture healing.

From the Research

Management of Prosthetic Fractures Adjacent to the Femoral Stem

• The management of prosthetic fractures adjacent to the femoral stem is a complex issue, with various treatment options available, including revision total hip arthroplasty and open reduction and internal fixation (ORIF) 2, 3, 4, 5.
• Revision total hip arthroplasty is indicated for most periprosthetic fractures that occur around the stem of the femoral implant, with a probability of survival of 90% at five years and 79.2% at ten years 2.
• ORIF is a viable option for managing Vancouver B2 fractures in the proximity of a polished tapered stem when anatomical reduction is possible, with lower hip-related complications compared to stem revision 3, 4, 5.
• The choice of treatment depends on various factors, including the type of fracture, the condition of the bone and implant, and the patient's overall health and mobility 6.

Treatment Options

• Revision total hip arthroplasty:
  • Indicated for most periprosthetic fractures around the stem of the femoral implant 2.
  • Can be performed with a cemented or uncemented stem, with better results seen when an uncemented, extensively porous-coated stem is used 2.
• Open reduction and internal fixation (ORIF):
  • A viable option for managing Vancouver B2 fractures in the proximity of a polished tapered stem when anatomical reduction is possible 3, 4, 5.
  • Offers lower hip-related complications compared to stem revision 3.
  • Can be performed with a lower risk of mortality and complications compared to stem revision 5.

Outcomes and Complications

• Revision total hip arthroplasty:
  • Can result in prosthetic loosening and fracture nonunion 2.
  • Has a probability of survival of 90% at five years and 79.2% at ten years 2.
• Open reduction and internal fixation (ORIF):
  • Can result in fracture healing and return to pre-injury mobility 4.
  • Has a lower risk of hip-related complications compared to stem revision 3.
  • Can be associated with a higher risk of mortality in the short-term, but with similar complication rates in the long-term compared to stem revision 3, 5.