Removal
Type B2 and B3 Fractures
Loose Implant
Bone Loss
Revision Arthroplasty
Bone graft
Case Example
Initial Cerclage Reduction
Plate Application
Long Fixation Span
Periprosthetic Fractures Classification and Treatment
Increasing Numbers
More Arthroplasties More Internal Fixation
Osteoporotic Fractures More Independent Elderly More Revisions
Critical Factors
Stability Of The Prosthesis
Locate To Prosthesis
Quality Of Bone
Patient
Age Medical Condition Baseline Status
Conclusions
Vancouver Classification Helpful in Treatment Decisions Indirect Reduction If Plate Used Cables and Onlay Grafts Helpful Think LONG on Plates and Nails Always Think of the Next Operation
Cables Collared Implant
Perforations
Longer Stem-bypass Perforation By 2 1/2 Canal Diameters +/- Supplemental Bone Grafting
Periprosthetic Fractures Risk Factors
Type B3
Implant Is Loose Inadequate Bone Stock
Treatment
Type A - Trochanteric Region
Usually Stable Protected WB ORIF
Cables Plate Plate + Cables
?????????
Berry et. al. 2007
“…it is becoming a little bit of a mini epidemic.” D. Berry, MD
Intraoperative Fracture Treatment
Fracture Proximal To Lesser Trochanter
Incidence Increasing
Between 1987 – 2003
Incidence 0.14%
Between 2004 – 2007
Incidence 0.78%
????????? Earlier Mobilization Smaller Incisions Proximally Coated Stems
Function
Treatment
Many Option / Permutations
Non-operative Revision Arthroplasty
And / Or ORIF
And / Or Strut Grafting
No Clear Consensus
Each Case Must Be Individualized
Decreased bone strength Perforations Loose stem Osteolysis Stress risers
Screw holes
Treatment Goals
United Fracture Anatomic Alignment Stable Prosthesis Early Mobilization Return To Previous
Treatment Vancouver Type B Fractures
Most Difficult
Type B1
Stable Implant No Bone Loss ORIF Vs Revision??? +/- Cortical Onlay Strut Grafting???? Consider Difficulty of Stable Implant
Vancouver Type C Treatment
ORIF
Avoid Stress Riser Between Implants
Overlap Fixation Device With Implant
Maintain > 2 ½ Cortical Diameters Between Devices
Vancouver Classification (Fractures About THA Stems)
Considerations
Location Of The Fracture
Implant Stability
Bone Quality
Vancouver Classification
Type determined by location Type A
Thank You
Trochanteric region
Type B
About tip of stem
Type C
Distal to tip of stem
Type B (At Tip) Sub Classification
Type B1
Implant Is Stable
Type B2
Implant Is Loose Satisfactory Bone