Kyle F. Dickson, M.D. M.B.A.

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Kyle F. Dickson, M.D. M.B.A.
Professor Baylor College of Medicine Southwest
Orthopaedic Group, Houston, Texas
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Place of Revision Joint Replacement

• Kyle Dickson MD, MBA
• Professor Baylor College of Medicine
• Southwest Orthopaedic Group, Houston Texas

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Arthroplasty
Trauma
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Peri-prosthetic Epidemic??

• Increasing incidence
• Prevalence arthroplasty
• Graying of America
• Increased lifespan
• 1 rising diagnosis peri-prosthetic femur
  fracture (OTA, 2003)

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Challenges in Osteoporosis

• Reduction reduction clamps or reduction screws
  pull out
• Loss of reduction due to hardware failure
• Sick and higher mortaliy
• Soft tissue concerns

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Hip Fracture PATIENT Outcome Predictors

• Pre-injury physical cognitive status
• Ability to visit a friend or go shopping
• Presence of home companion
• Postoperative ambulation
• Postoperative complications (Cedar,
  Thorngren, Parker, others)

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Treatment Goals

• Restore axial alignment and length
• Stable fixation
• ROM as soon as possible
• Maintain fracture enviroment suitable for boney
  healing
• Return to pre-injury mobility
• Op treatment best accomplishes these goals

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Classification

• Undisplaced fracture
• Prosthesis intact

Type I Type II Type III

• Displaced fracture
• Prosthesis intact

• Displaced or Undisplaced fracture
• Prosthesis loose

Lewis and Rorabeck (1997)
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VP

• 50 yo MVA femur fx
• EtoH
• 1pk/day tobacco
• Insulin dependent diabetic
• gt20 yo hip fracture with increasing hip pain
  seeking medical intervention

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• Options?

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Treatment Options (type?)

• Anterior plating conventional vs locked (leave
  DHS)?
• Plating (remove DHS)?
• IM nail ante vs retro (remove DHS)?
• THA and plate?
• Other options?

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Biomechanical Evaluation of the LISS, Angled
Blade Plate, and the Retrograde Intramedullary
Nail for the Fixation of Distal Femur Fractutres
An Osteoporotic Cadaveric ModelKregor OTA 2002

• Osteoporotic cadaveric femuri (age 70 yo)
• Tested to failure in axial loading and torsion
• Axial loading 34 higher load for LISS Vs blade
  plate and 24 higher than IMN
• Loss of distal fixation with CBP and IMN
• Plastic deformation with LISS and no loss of
  distal fixation
• Torsion strength same for CBP, but higher for IMN

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Evolution
Or something completely different?
You be the judge!
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Any other studies?
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Treatment
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Plating Technique?
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Comments?

• Type of plate?
• gt300 LISS no hardware failures 2 surgeon errors
• gt50 locking condylar 7 hardware failures (surgeon
  error?)

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FU 1 1/2 yr
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Periprosthetic Fracture
58 y.o. female s/p multiple revisions R THA low
energy fall
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Periprosthetic Fracture
-ORIF articular component - CR LISS plate shaft
- circlage cable prosthesis
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Periprosthetic Fracture
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Case

• 64 yo with no real pain prior to a fall
• Previous hip surgery for AVN 20 years ago

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Questions

• Stem loose?
• Cup loose?

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Options

• Revise both cup and stem?
• Cerclage fractures around stem with a plate?
• Revise just the femur to long stem implant with
  cerclage wires?
• Revise femur and use plate (type?)?
• Other tests?

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Case

• Elevated C-reactive protein and ESR (wbc nl)
  staged removal and cultures and traction (cement
  spacer?)
• Scanogram bilaterally

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The Problem
Distal Fixation
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Treatment Options

• Retrograde intramedullary nail
• Conventional plating (blade plate)
• Locked plating
• Revision with stemmed prosthesis, allograft, or
  tumor prosthesis

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Biology and BonePreserve the periosteum

• Evolution
• DCP
• Large footprint, frictioned to bone
• LCDCP
• Smaller footprint, still frictioned to bone
• LCP
• Point contact with bone, no frictioning

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Direct Reduction

• fracture manipulated with bone-holding forceps or
  levers
• negative biologic impact

Choke Kill
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15 months post-op
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77 yo F with femur nonunion
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Retrograde Nailing

• Is the notch open or closed?
• If open, is it large enough?
• Narrow notch and closed box seen in posterior
  stabilized knees

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Summary - Nails

• Know the characteristics of the nail you use
• Consider curve mismatch
• Avoid anterior cortex impingement
• Consider longer nails than shorter
• Consider Locking distally
• Pending data!

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Retrograde Intra-medullary Nail

• Nail size canal diameter mismatch
• Must have two interlocking screws distally

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Constrained Rotating Hinge
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Constraint Comes at a Price!!
Peri-prosthetic fracture
Non union and broken plate
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Inter-Device Distance (IDD)
lt12cm
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Interprosthetic Fractures

• Similar principles
• Overlap stems when present
• Avoid retrograde nail
• Stress concentration between nail and THA
• LISS for distal fractures

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Summary

• If prosthesis is looseRevise it
• If bone is missing.Graft it or strut it
• If prosthesis is stable...Fix the fracture
• Strut grafts not necessary
• Locked plates are better than standard plates
• Locked plates better than retrograde nails
• Splint the entire bone..the longer the better
• Overlapdont gap!

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Summary - patient

• Periprosthetic fracture are a growing epidemic
• Fractures are difficult manage
• Patients may be difficult to manage
• Team approach
• Consider functional goals for patient
• Consider skill of the surgeon

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Summary screws and surgery

• Screws better than wires
• Locked screws better than standard screws
• Bicortical locked screws better than unicortical
  locked screws
• Use indirect reduction techniques
• Use biologic, atraumatic surgery

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Conclusion

• Periprosthetic fracture are a growing epidemic
• Difficult management
• Locked plates helpful
• Maintain principles of fracture management

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Thank You