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
Removal
Type B2 and B3 Fractures
Loose Implant Bone Loss
Revision Arthroplasty
Bone graft
Case Example
Initial Cerclage Reduction
Plate Apan
Intraoperative Fracture Risk Factors
Cementless Implant Revision Surgery
Decreased Bone Strength
Osteoporosis Ra
Deformity Surrounding Implant
Type B1 Implant Is Stable Type B2 Implant Is Loose Satisfactory Bone Type B3 Implant Is Loose Inadequate Bone Stock
Treatment
Type A - Trochanteric Region
More Revisions
Incidence Increasing
Between 1987 – 2003
Incidence 0.14%
Between 2004 – 2007
Incidence 0.78%
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Earlier Mobilization Smaller Incisions Proximally Coated Stems
Thank You
Type determined by location
Type A Trochanteric region Type B About tip of stem Type C Distal to tip of stem
Type B (At Tip) Sub Classification
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Berry et. al. 2007
“…it is becoming a little bit of a mini epidemic.” D. Berry, MD
Intraoperative Fracture
Cemented Hip Stem < 1% incidence of fracture Cementless Hip Stem 3% - 20% incidence of fracture Revision arthroplasty 6.3% with cemented stem 17.6% with cementless stem
Individualized
Critical Factors
Stability Of The Prosthesis
Location Of The Fracture Relative To Prosthesis
Quality Of Bone Patient Age Medical Condition Baseline Status
Usually Stable Protected WB ORIF
Cables Plate
Plate + Cables
Vancouver Type C Treatment
ORIF
Avoid Stress Riser Between
Implants Overlap Fixation Device With Implant Maintain > 2 ½ Cortical Diameters Between Devices
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
Intraoperative Fracture Treatment
Fracture Proximal To Lesser Trochanter
Cables Collared Implant
Perforations
Longer Stem-bypass Perforation By 2 1/2 Canal Diameters +/- Supplemental Bone Grafting
Periprosthetic Fractures Risk Factors
Decreased bone strength Perforations
Loose stem
Osteolysis
Stress risers
Screw holes
Treatment Goals
United Fracture
Anatomic Alignment
Stable Prosthesis
Early Mobilization
Return To Previous
Function
Treatment
Many Option / Permutations Non-operative Revision Arthroplasty And / Or ORIF And / Or Strut Grafting No Clear Consensus Each Case Must Be
Vancouver Classification (Fractures About THA Stems)
Considerations
Location Of The Fracture Implant Stability Bone Quality
Vancouver Classification
Periprosthetic Fractures Classification and Treatment
Increasing Numbers
More Arthroplasties
More Internal Fixation
Osteoporotic Fractures
More Independent Elderly