The Treatment of Periprosthetic Fractures

Home , Femoral fracture, Vancouver classification

Aaron Nauth, MD, FRCSC Markku T. Nousiainen, MD, FRCSC Richard Jenkinson, MD, MSc, FRCSC Jeremy Hall, MD, FRCSC, MEd

Abstract The management of periprosthetic fractures is an issue of increasing importance for orthopaedic surgeons. Because of the expanding indica- tions for total joint arthroplasty (TJA) and an aging population with increasingly active lifestyles, the incidence of primary and revision TJA is increasing, and there is a corresponding increase in the prevalence of periprosthetic fractures about a TJA. The management of these fractures is often complex because of issues with obtaining ﬁ xation around implants, dealing with osteopenic bone or compromised bone stock, and the potential need for revising loose TJA components. In addition, these injuries frequently occur in frail, elderly patients, and the literature has demonstrated that both morbidity and mortality in these patients is similar to that of the geriatric hip fracture population. As such, the early restoration of function and ambulation is critical in patients with these injuries, and effective surgical strategies to achieve these goals are essential. Instr Course Lect 2015;64:161–173.

This chapter reviews the current ev- Lower Extremity rare injuries, with an incidence of ap- idence regarding the management of Proximal Femur proximately 1% after primary THA periprosthetic fractures of the upper Periprosthetic fractures of the fe- and 4% after revision THA, the con- and lower extremities. Fracture fi xation mur represent an important potential sequences of these fractures are sub- and revision arthroplasty techniques are complication of total hip arthroplasty stantial.1 The 1-year mortality rate after discussed. (THA). Although these are relatively surgical fi xation of these injuries is as high as 11%, which parallels that of the hip fracture population.2 Dr. Nauth or an immediate family member has received research or institutional support from Capital Sports Entertain- ment, Synthes, Stryker, and Sonoma Orthopaedics. Dr. Nousiainen or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Zimmer; serves as a paid consultant to or is an employee of Classifi cation Zimmer; has received research or institutional support from Smith & Nephew and Synthes; and serves as a board member, The most commonly used classifi cation owner, offi cer, or committee member of the Canadian Orthopaedic Association, the AOTK Group (Computer-Assisted Surgery Group for North America), and the Orthopaedic Trauma Association. Dr. Jenkinson or an immediate family system for periprosthetic proximal fem- member has received research or institutional support from Zimmer, Synthes, and Biomet. Dr. Hall or an immediate family oral fractures is the Vancouver classi- member is a member of a speakers’ bureau or has made paid presentations on behalf of Stryker and Zimmer; serves as a fi cation, which stratifi es these injuries paid consultant to or is an employee of Zimmer; has received research or institutional support from Pfi zer, Zimmer, Synthes, Stryker, Smith & Nephew, Amgen, and Biomimetic; and has received nonincome support (such as equipment or services), based on the location of the fracture commercially derived honoraria, or other non–research-related funding (such as paid travel) from Pfi zer, Zimmer, Synthes, and the stability of the implant3 (Ta- Stryker, Smith & Nephew, and Amgen. ble 1). This classifi cation system is

Table 1 revision and fracture ﬁ xation. The Vancouver Classiﬁ cation of Periprosthetic Femoral stem should bypass the fracture by at

Fractures in Total Hip Arthroplasty least two cortical diameters. Type B3 fractures require revision, ORIF, and, Type Fracture Description Treatment oftentimes, allograft to restore bone A Fracture around the trochanters Mainly conservative. ORIF for displaced greater trochanter fractures stock. Type C fractures occur well A Greater trochanter G or loose stems below the stem and can generally be A Lesser trochanter L treated with isolated ORIF. B Fracture about the stem or just distal The focus of this section is the B1 Stable implant ORIF (cable/locking plate, strut allograft) management of type B1 fractures that require fi xation around a well-fi xed B2 Loose implant with good bone stock Diaphyseal engaging implant implant. It is of critical importance to B3 Loose implant with poor bone stock Diaphyseal engaging implant; consider allograft supplementation confi rm the stability of the implant in C Well below the implant ORIF this setting because the most commonly

ORIF = open reduction and internal fi xation. cited reason for the failure of fi xation when treating these fractures is implant relatively simple, is reliable, and serves authors fi nd CT useful for evaluating loosening, presumably caused by un- to guide treatment. stem loosening if radiographic fi nd- recognized loosening associated with ings are inconclusive. To differentiate the fracture.5 A careful assessment of

Imaging between type B2 and B3 fractures, an preoperative imaging to evaluate for any Diagnosis, classifi cation, and subse- assessment of bone stock is necessary signs of implant loosening is critical; quent surgical management rely on the and is based on the appearance of the if any doubt remains, implant stability careful evaluation of AP and lateral cortices and the generalized density of should be confi rmed intraoperatively by radiographs of the entire femur and hip. the bone on radiographs. either examining the bone-implant in- Location, displacement, comminution, terface through the fracture site or with and the surrounding bone stock should Management an arthrotomy of the hip and stressing be carefully assessed. Radiographs also The management of periprosthetic of the implant. Corten et al6 reported should be critically assessed for signs fractures of the femur about a THA is that 20% of implants judged as stable of implant loosening to distinguish be- based on the Vancouver classifi cation. based on preoperative radiographs were tween type B1 and B2 fractures. When- Type A L fractures involving the lesser found to be loose at the time of surgery. ever possible, preinjury radiographs trochanter are generally treated nonsur- The optimal fi xation strategy for should be obtained for comparison. gically, unless they extend substan tially type B1 fractures continues to be an The implant-bone, cement-implant, into the calcar and affect prosthesis issue of substantial controversy, with and cement-bone interfaces should be stability. (In this setting they are best some authors advocating for cable plat- carefully evaluated. Radiographic signs classifi ed as type B2.) Type AG fractures ing combined with an anterior allograft of defi nite loosening include progres- involving the greater trochanter are strut (Figure 1) and others advocat- sive periprosthetic or cement mantle managed nonsurgically if nondisplaced ing for isolated lateral locked plating7,8 lucency, a change in the position of the or only minimally displaced. Displaced (Figure 2). Regardless of the fi xation stem, and component or cement frac- fractures are treated with open reduc- strategy used, several biomechanical ture.4 Radiographic signs of probable tion and internal fi xation (ORIF) with and surgical principles must be adhered loosening include greater than 2 mm or without bone grafting and liner ex- to when treating these fractures. First, of periprosthetic or cement mantle change if associated with eccentric wear proximal fi xation around the stem is lucency around the entire prosthesis, of the polyethylene liner and substantial best achieved with a combination of bead shedding, endosteal scalloping, osteolysis. Type B1 fractures are treated wires or cables and screws, and it is and endosteal bone bridging at the tip with isolated ORIF. Type B2 fractures critical that suffi cient overlap of the of the stem. Occasionally, this chapter’s are treated with femoral component femoral prosthesis be obtained to avoid

Figure 1 Preoperative AP radiographs of the hip (A) and femur (B) showing a periprosthetic femoral fracture below

a well-fi xed total hip arthroplasty (Vancouver type B1) in an elderly woman. Postoperative AP radiographs of the hip(C) and femur (D) and lateral view of the femur (E) demonstrating fi xation with a lateral plate, an anterior allograft strut, and cables. mechanical failure9 (Figure 3). Second, (for example, diphosphonate-associat- These fractures present a unique set of it is imperative that the fracture is fi xed ed fractures, diabetes, and smoking), management challenges. The goals of without the stem in varus because in- or osteopenic bone. The biomechan- treatment of a periprosthetic fracture creased rates of fi xation failure have ical literature supports this construct around a well-fi xed TKA include (1) a been reported with varus positioning of as being the most stable and further healed fracture; (2) appropriate length, the stem.10 On rare occasions, this can suggests that there is no advantage to alignment, and rotation of the limb; (3) a require revision of a well-fi xed implant locked versus nonlocked plating when painless, stable TKA; and (4) functional if it has been implanted in substantial combined with an allograft strut.11 Ad- range of motion of the knee. varus. It is important to adhere to the vocates of isolated lateral locked plating principles of absolute versus relative have reported good results and suggest Imaging and Investigations stability, which depend on the type of that this technique has the advantages High-quality radiographs of the affected fracture healing desired. In the setting of minimally invasive application and knee and femur should be carefully re- of a simple transverse or spiral fracture, the preservation of fracture biology.7,8 viewed to determine the location and absolute stability and compression at Comparative literature between the two the displacement of the fracture lines, the fracture site should be achieved techniques is lacking, and there is in- identify any comminution, assess the using compression plating or lag screw suffi cient evidence to provide a strong stability of the femoral component of fi xation. This is in contrast to commi- recommendation for one strategy over the TKA, and quantify the bone stock nuted fractures, which require relative the other. available for distal fi xation. CT scans are stability and spaced fi xation to allow valuable in evaluating these fractures, for fracture healing indirectly by callus Distal Femur and Stable particularly in regard to assessing the formation. Total Knee Arthroplasties distal bone stock and determining if the This chapter’s authors prefer to use The published incidence of peripros- femoral box is open and large enough to a cable plate with an anterior allograft thetic fractures of the distal femur above accommodate a retrograde nail. When- strut in a 90-90 confi guration, partic- a total knee arthroplasty (TKA) is be- ever possible, previous surgical notes ularly in the setting of fracture com- tween 0.2% and 2.5% for primary TKAs should be obtained to identify the exist- minution, impaired fracture biology and up to 30% for revision TKAs.12 ing prosthesis, confi rm that the femoral

Figure 2 Preoperative AP radiograph of the hip (A) and lateral view of the femur (B) showing a periprosthetic fracture

of the femur below a well-ﬁ xed total hip arthroplasty (Vancouver type B1) in an elderly woman. Postoperative AP radiographs of the hip(C) and femur (D) demonstrating ﬁ xation with an isolated lateral locking plate.

Figure 3 Six-week postoperative AP (A) and lateral (B) radiographs of the hip and femur showing a periprosthetic femoral fracture treated with a lateral plate, anterior allograft strut, and cables. Inadequate overlap of the femoral component was obtained proximally and the ﬁ xation failed into varus. Postoperative AP (C) and lateral (D) radiographs of the hip and femur demonstrate revision ﬁ xation with a lateral plate, anterior allograft strut, and cables with adequate overlap of the femoral prosthesis.

box is open and replacement is possible, Table 2 and verify that trial polyethylene liners Rorabeck and Taylor Classifi cation of Periprosthetic are available if a retrograde nailing tech- Distal Femoral Fractures in Total Knee Arthroplasty nique is chosen for management. Type Fracture Description Type 1 Nondisplaced fracture with no loosening of components Classifi cation Type 2 Displaced fracture (>5 mm of displacement or 5° of angulation) with no The Rorabeck and Taylor classifi cation loosening of components system is the most commonly used clas- Type 3 Any supracondylar fracture associated with loosening of components sifi cation system for periprosthetic fractures of the distal femur above a TKA13 (Table 2). Although it remains useful, this classifi cation lacks some important information that pertains to management, including distal bone stock and the location of the fracture.

Treatment In nondisplaced fractures, nonsurgical treatment in the form of a cast or a hinged brace with protected weight bearing may be considered. Close radiographic surveillance is required to ensure that fracture displacement does not occur. As a result of high rates of nonunion, malunion, and knee stiffness Figure 4 A, Preoperative AP radiograph of the left knee and femur of an el- after the nonsurgical management of derly man showing an open periprosthetic distal femoral fracture above a well- displaced periprosthetic fractures of the fi xed total knee arthroplasty. Postoperative AP (B) and lateral (C) radiographs distal femur, nonsurgical treatment is of the left knee and femur demonstrate fi xation with retrograde intramedullary nailing. Extension deformity on the lateral radiograph demonstrates the typical reserved for nonambulatory patients or malunion deformity that occurs with retrograde intramedullary nailing. those who cannot tolerate anesthesia.14 Surgical treatment is indicated for literature regarding locked plating ver- rates with locked plating. The authors most patients. Modern options for the sus retrograde intramedullary nailing. concluded that locked plating may offer surgical treatment of fractures with In general, the literature has shown some advantages over retrograde intra- a stable implant (type 1 or 2) include good outcomes with either technique, medullary nailing, but further research locked plating or retrograde intramed- but comparative literature between the is needed. ullary nailing. Two separate systematic two is lacking.17-25 A recent systematic There are several important situa- reviews have shown that both locked review by Ristevski et al16 compared tions in which retrograde intramedul- plating and retrograde intramedullary locked plating with retrograde intra- lary nailing cannot be used, including nailing have important advantages over medullary nailing for the treatment of the presence of a closed femoral box or nonlocked plating in regard to improved distal femoral fractures above a TKA. a stemmed femoral component (Fig- union rates and decreased rates of mal- The authors reported that retrograde ure 5), an ipsilateral THA, or an ex- union and secondary surgical proce- intramedullary nailing had a statistical- tremely distal fracture where suffi cient dures.15,16 As such, it is generally agreed ly signifi cant higher rate of malunion fi xation cannot be obtained with distal that these fractures are best treated with compared with locked plating (Fig- locking screws.19 In these situations, one of these two constructs. However, ure 4); however, there was a nonsignif- the fracture is best treated with locked there is substantial controversy in the icant trend toward increased nonunion plating. When using a locking plate, it is

Figure 5 Preoperative AP radiographs of the knee (A) and distal femur (B) of an elderly woman show a periprosthetic distal femoral fracture above a well-fi xed total knee arthroplasty. The stemmed femoral component precludes intramedullary nailing. Postoperative AP (C) and lateral (D) radiographs of the distal femur and knee demonstrate fi xation with a lateral locking plate. important to adhere to the principles of uncommon, and there is very limited osteolysis. Metaphyseal (type 2) frac- absolute versus relative stability. Simple literature available. tures occur around the keel/short stem fracture patterns should be treated with of modern primary TKA designs. Re- a construct that provides absolute sta- Classifi cation vision arthroplasty is required if the bility to promote primary bone healing. The Mayo classifi cation subdivides prosthesis is loose or failing or if there Multifragmentary fractures should be these fractures based on the anatomic is insuffi cient bone stock available for treated with a construct that provides location: (1) medial or lateral tibial pla- fracture fi xation. Revision is typically relative stability (such as bridge plating) teau, (2) adjacent to stem/keel (meta- performed with a stemmed revision so as to lead to secondary bone healing. physeal), (3) distal to stem (diaphyseal), prosthesis to bypass the defect, com- The management of distal femoral and (4) involving the tibial tubercle. bined with a strategy for managing ex- fractures above a stable TKA requires Injuries are further subclassifi ed based pected bone loss. For smaller defects, careful consideration of the issues de- on whether the fracture is associated bone loss can be managed with metal scribed earlier because there is sub- with a well-fi xed prosthesis, is associ- augments; however, large defects may stantial controversy regarding the ideal ated with a loose prosthesis, or occurs require bulk allografts or trabecular fi xation construct. Further research is intraoperatively.26 metal cones. needed to clarify these issues and guide ORIF is preferred when the TKA management. Treatment is stable and there is suffi cient bone Revision arthroplasty is required for for stable fi xation. This situation is the Proximal Tibial most type 1 fractures involving the norm for diaphyseal periprosthetic tib- Fractures and TKAs tibial plateau because these usually oc- ial fractures (type 3) and often the case Periprosthetic tibial fractures cur in association with a loose TKA for metaphyseal fractures (type 2). The around knee prostheses are relatively secondary to polyethylene wear and main challenge to surgical treatment is

Figure 6 A, Preoperative AP radiograph of the left tibia of an elderly man showing a periprosthetic fracture in the metaphyseal region (type 2) below a well-fi xed total knee arthroplasty. Postoperative AP view of the left tibia (B) and lateral view of the knee (C) demonstrate fi xation with medial and lateral locking plates. D, Intraoperative photograph showing minimally invasive insertion of the medial plate. the presence of the tibial component, which precludes the use of an intramedullary nail and complicates proximal fi xation. Strategies to manage this situation include locking plate fi xation (plus or minus variable angle-locking screws) as well as the use of multiple plates to stabilize the proximal segment (Figure 6). Infection is a serious complication in the setting of an arthroplasty. The soft tissue should be respected, and minimally invasive strategies can be attractive to possibly reduce infection rates and promote union. Figure 7 Lateral radiograph (A) and CT scan (B) of a very distal peripros- Revision Arthroplasty thetic femoral fracture above a total knee arthroplasty (TKA) with very limited for Periprosthetic distal bone stock in an elderly woman. Postoperative AP radiograph (C) Fractures and TKAs shows revision with a semiconstrained TKA and distal femoral allograft. With a stable prosthesis, fi xation is usually preferable to revision arthroplasty a universally agreed-on threshold with be insuffi cient bone for distal fi xation to avoid the creation of very large bone regard to distal bone stock, a tailored alone but enough salvageable bone that, defects. There is some controversy in approach is required, with the treating after healing, some support for the the literature regarding the necessary surgeon understanding the available prosthesis and supporting ligaments amount of distal bone for fracture fi xa- fracture implants and whether they will will be present (Figure 8). In this sit- tion.25 This determination is most often have suffi cient purchase in the available uation, limited ORIF of the condyles made based on a thorough radiographic distal bone. can maintain bone stock and the lig- review, typically including CT scans if After determining that a revision is amentous attachments, thus reducing the quality of the distal bone stock is in required, two major scenarios are pos- the amount of constraint required in the question (Figure 7). In the absence of sible. The fi rst scenario is that there will prosthesis while preserving anatomy

Figure 8 Preoperative AP (A) and lateral (B) radiographs of the right knee of an elderly woman showing a periprosthetic distal femoral fracture above a total knee arthroplasty (TKA) with limited distal bone stock. Postoperative AP (C) and lateral (D) radiographs of the right knee show revision to a partially constrained TKA with limited open reduction and internal fi xation of the femoral condyles. for potential future revisions. The re- demanding option. Arthroplasty using factors for such fractures include ad- vision construct will require stems that a distal femoral replacement is a tech- vanced age, female sex, a prior history bypass the metaphyseal region as well nically easier and quicker procedure, of fracture, osteoporosis, rheumatoid as a partially constrained prosthesis but it is associated with high prosthesis or infl ammatory arthritis, and revision (varus-valgus constrained) to protect cost and diffi culties with later revision. surgery.27-31 Periprosthetic fractures in the repaired ligamentous origins. How- However, distal femoral replacement the upper extremity may occur intra- ever, a fully constrained hinge is usually offers the advantage of immediate sta- operatively or postoperatively.27,32 In not required. bility and weight bearing in a patient general, intraoperative fractures most The second scenario occurs when population that is typically elderly and frequently occur during the insertion there is essentially no functional distal prone to complications from prolonged of trial or defi nitive components or bone to support the revision prosthesis. immobilization. A carefully considered the removal of components during re- This is the more common scenario, usu- and individualized approach is required vision surgery.27,33 Fractures also may ally occurring in elderly patients with to optimize the outcomes in these situ- occur during reduction or dislocation very poor bone quality. Revision arthro- ations, taking into account patient fac- maneuvers, positioning of retractors, plasty with management of the massive tors and institutional expertise. retraction against resistant soft tissues, bone defect is required. Options include overzealous reaming or broaching, using either a distal femoral allograft Upper Extremity or during procedures for joints with (Figure 7) or a tumor-type distal fem- Periprosthetic fractures in the upper ex- substantial deformity. Postoperative oral replacing prosthesis (Figure 9). tremity are relatively uncommon com- fractures may be a late presentation of For younger patients with expected pared with those of the lower extremity. an unrecognized intraoperative event, longevity to require future revision, the However, with increasing numbers of occur as the result of a low-energy fall retention of bone stock or the replace- upper extremity joint arthroplasties be- or (less frequently) high-energy trauma, ment of bone stock with bulk allograft ing performed each year, these fractures or present in association with a loose is an attractive but more technically will likely be seen more commonly. Risk component.30

Table 3 revision surgery. At the time of surgery, Wright and Cofi eld glenoid bone stock must be assessed, Classifi cation of Periprosthetic and consideration should be made for Humeral Fractures in using structural bone graft if primary Shoulder Arthroplasty fi xation of the fracture is not possible.

Type Fracture Description After reconstruction of the glenoid, Type A Begins at the tip of the the construct should be evaluated, and prosthesis and extends the anticipated stability of the glenoid proximally assessed. If there is uncertainty regard- Type B Begins at the tip of the pros- ing the stability of the glenoid, consid- thesis and extends distally eration should be given to a staged Type C Occurs well distal to the stem procedure.

glenoid components in the setting of Humeral Fractures both total shoulder arthroplasty and Periprosthetic humeral fractures associ- reverse shoulder arthroplasty become ated with either hemiarthroplasty of the more popular. Periprosthetic glenoid shoulder or total shoulder arthroplasty fractures noted intraoperatively require are relative uncommon, occurring at a a careful assessment of remaining gle- rate of 0.5% to 3%.30,34 noid bone stock and the anticipated There are several classification stability of the implanted prosthesis. systems for periprosthetic humeral Often, the fracture occurs during fractures. The Wright and Cofi eld clas- preparation or impaction of an unce- sifi cation system describes the location mented glenoid component, leading to of the fracture relative to the prosthe- a split of the anterior or the posterior sis31 (Table 3; Figure 10). aspect of the glenoid surface.29 If the Intraoperative periprosthetic humer- fracture can be reduced and appropri- al fractures often occur secondary to ately stabilized and the prosthesis can poor bone quality in association with Figure 9 Intraoperative photograph of a distal femur-replacing be placed on stable host glenoid bone, overzealous reaming, broaching, and tumor prosthesis. then insertion of the glenoid compo- trialing, particularly with uncement- nent can proceed. In the setting of ed prostheses. Careful preoperative Shoulder Arthroplasty reverse shoulder arthroplasty, screw templating to anticipate implant siz- The incidence of periprosthetic frac- fi xation placed through the base plate ing may help decrease fracture risk. tures about a shoulder arthroplasty has may further facilitate both fracture and Metaphyseal fractures can occur with been reported to range from 0.6% to implant stability. If stability of the im- aggressive proximal humeral retraction 3%, with most fractures occurring ei- plant cannot be achieved with fracture for access to the glenoid. When iden- ther intraoperatively or postoperatively fi xation, consideration should be given tifi ed intraoperatively, humeral shaft as a result of low-energy trauma.30,33 to staging the procedure with a humer- and metaphyseal fractures should be al hemiarthroplasty or an excision ar- reduced and stabilized with cerclage Glenoid Fractures throplasty and a plan to return after the wires and/or plate and screw fi xation or There is a paucity of literature pertain- glenoid fracture has healed suffi ciently allograft struts combined with a long- ing to periprosthetic glenoid fractures. to implant a stable glenoid component. stem humeral component to bypass the These fractures are relatively rare and Postoperative glenoid fractures are of- fracture by at least two cortical diam- most often occur intraoperatively. It is ten displaced and may be associated eters.28,34,35 Tuberosity fractures should anticipated that the incidence of these with glenoid component wear and/or be addressed with anatomic reduction fractures may increase as uncemented loosening. Most often, this necessitates and suture fi xation to the surrounding

cementing the component and accept- ing the associated increase in nonunion risk.35 Periprosthetic fractures of the humerus noted in the postoperative period can occur because of trauma or may be a delayed presentation of an intraoperative fracture. Nonetheless, treatment is dictated by the stability of the humeral component and the overall fracture alignment. Substantially displaced tuberosity fractures will inevitably lead to poor rotator cuff function, and consideration should be made for reconstruction.36 Fractures of the humeral shaft associated with a stable prosthesis and reasonable fracture alignment can be treated nonsurgically.30,35 However, consideration can be given for surgi- Figure 10 Illustrations of the Wright and Cofi eld classifi cation of periprosthetic humeral fractures after shoulder arthroplasty. A, Type A cal fi xation to allow for early range fractures begin at the tip of the prosthesis and extend proximally. B, Type of motion. Fractures associated with B fractures begin at the tip of the prosthesis and extend distally. C, Type C unstable humeral components require fractures occur well distal to the stem. (Reproduced with permission from Wright TW, Cofi eld RH: Humeral fractures after shoulder arthroplasty. J Bone revision surgery and fracture fi xation. Joint Surg Am 1995;77[9]:1340-1346.) Humeral shaft fractures with substantial displacement or unacceptable alignment should be considered for surgical fi xation and are often treated with a combination of plate and screw, cable, and allograft strut fi xation (Figure 11).

Periprosthetic Fractures After Total Elbow Arthroplasty The incidence of fractures after total elbow arthroplasty has been reported to be approximately 5% after primary surgery.37 Fractures of the humerus or the ulna associated with total elbow arthroplasty are treated in a similar man- ner to periprosthetic humeral fractures Figure 11 A, Preoperative AP radiograph of a periprosthetic humeral associated with shoulder arthroplasty. shaft fracture below a loose and failing hemiarthroplasty of the shoulder. Postoperative lateral (B) and AP (C) radiographs show revision to a long- stemmed component and ﬁ xation of the fracture with allograft strut and Classiﬁ cation cables. Periprosthetic fractures about a total elbow arthroplasty are described by bone and/or prosthesis. Humeral com- stable, uncemented construct cannot be the Mayo classification37 (Fig- ponent stability must be assessed; if a achieved, the surgeon should consider ure 12). Type I fractures occur in the

periarticular or the metaphyseal region, including the humeral condyles and the olecranon. Type II fractures occur at the level of the humeral or the ulnar component, and type III fractures occur either proximal to the humeral component or distal to the ulnar component. These are further subdivided to account for bone quality and implant stability.

Humeral Fractures Similar to the shoulder, intraoperative humeral fractures occurring during total elbow arthroplasty can occur as a result of poor bone quality, retraction, or overzealous reaming and broaching.37 Fractures proximal to the tip of the prosthesis (type III) should be Figure 12 Illustration of the Mayo classifi cation of periprosthetic humeral exposed, reduced, and reconstructed and ulnar fractures about a total elbow arthroplasty. Type I fractures occur in using allograft strut or plate and screw the periarticular or the metaphyseal region, including the humeral condyles or cable techniques. Fractures about and the olecranon. Type II fractures occur at the level of the humeral or ulnar component, and type III fractures occur either proximal to the humeral the stem (type II) may be treated with component or distal to the ulnar component. (Reproduced with permission reduction, cemented long-stem com- from Ricci WM, Haidukewych GJ: Periprosthetic fractures, in Bucholz RW, ponents, and cerclage wiring with or Court-Brown CM, Heckman JD, Tornetta P III, eds: Rockwood and Green’s 38 Fractures in Adults, ed 7. Philadelphia, PA, Lippincott, Williams and Wilkins, without allograft struts (Figure 13). 2010, p 584.) Fractures involving the medial or lateral columns of the distal humerus (type I) may be left in situ, reconstructed, or of allograft struts is required in their Ulnar metadiaphyseal fractures (type resected in the setting of a semicon- management. II) can be treated with cerclage wires strained hinged prosthesis.39 In the set- and long-stem components, whereas ting of an unconstrained elbow implant, Ulnar Fractures fractures occurring distal to the implant these fractures must be anatomically Periprosthetic ulnar fractures are un- (type III) often require fi xation with reduced and fi xed because postopera- common. In general, these fractures are plate and screw or allograft and cer- tive elbow stability depends on these managed surgically to maintain forearm clage wire constructs.42,43 Fractures of structures; otherwise, revision to a function. Intraoperative ulnar fractures the ulna noted in the postoperative pe- constrained implant may be necessary.40 may occur secondary to poor bone riod commonly require surgical fi xation Postoperative fractures associated with quality and ulnar component prepara- and/or revision based on the stability substantial displacement or prosthesis tion. Periprosthetic olecranon fractures of the implant. As with periprosthetic loosening should undergo revision and (type I) must be evaluated for stability. humeral fractures, allograft struts are fi xation, whereas fractures with stable Very proximal unstable fractures can often required. components and reasonable alignment be treated with either suture fi xation or may be considered for nonsurgical man- triceps advancement techniques. More Summary agement in selected patients.38 Because distal olecranon fractures may ade- Periprosthetic fractures associated with bone stock is often an important issue quately be treated with a tension-band total joint arthroplasty are expected to with these fractures, the frequent use wiring technique or plate fi xation.41 increase dramatically in the future.

Figure 13 Preoperative AP (A) and lateral (B) radiographs of the right elbow of an elderly woman showing a periprosthetic humeral shaft fracture above a loose and failing total elbow arthroplasty (TEA). Postoperative AP (C) and lateral (D) radiographs show revision TEA and fracture ﬁ xation with allograft struts and cables.

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