11/19/2018 interprostheticfractures: challenges, options
TRANSCRIPT
11/19/2018
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Frank Liporace, MDChairman & VP, Dept of Orthopaedics
Chief of Trauma & Adult Reconstruction Jersey City Medical Center / RWJ Barnabas Health
Interprosthetic Fractures:Challenges, Options, Techniques
Reasons Susceptible
• Rate of Arthroplasties
• Lifetime Risks - 7% chance peri-implant failure all comers
• Intramedullary stems (Lehman W, et al 2011; Rupprecht M, et al 2012)
– Decreased strength over time of femur
• Osteoporosis
Considerations• Implants above and
below– TJR + stems
– Fracture implants• Healing of prior
injury?
• Implant stability
• Bone Quality
• Location of injury
• Infection?
• Available Bony Real estate
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Decision Matrix
MF
Issues:- IT healed- Lag screw track- Distal real estate
MF
Ca PO4 screw tract augmentation+
Span entire femur with long plateCaPO4 vs PMMACollinge et al JOT 2007
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NH
Use your surroundings:- Cement mantle- Implant - Stay anterior - lateral
NH
-Get at least 2 cortical diameter overlap-Have some form of proximal screw fixation
Brooks et al 1987Bryant et al 2009
NH
COMMINUTION Bridge Plate, Percutaneous Application !!!
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97 yo retired nurse 3 wks s/p HHA for FNF
•Fracture
•TKR below
•Stem Loose?
•Infection?• Time since procedure?
FAL
Options:
-Cables + Plate / Allograft
-Cables + Revision Stem
FAL
Other Considerations:
-Fall Risk
-Osteoporosis
• WB’ing status post-op?
FAL
• Augmented & Prophylactic plating
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GP-92 year old: Failed FNF screws 15 yrs earlier
-Intra-op fx THA with “fixation”
-10 years ago supracondylar femur fx
-Pain, can’t ambulate last 8-9 months
ISSUES:-Stem protrusion
-Femoral perforation
-DeformityFAL
GP
-Mega Prosthesis-Prophylactic Plating
What to do?
Infected?
Nonunion & Implant Failure
SE – 67 yo F; s/p total of 40+ lifetime surgeries - 3 strikes this
hip
FAL
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SE – 3 strikes
Resection Nonunion
Antibiotic Coated Plate
Antibiotic Spacer HHA
FAL
Stage 2
Plate Exchange
Revision THA
SE – 3 strikes
FAL
SE – 3 strikes
FAL
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JV – 57 yo male
3 time failed distal femoral nonunion
ALL surgeries with lateral plate
Previous Hip Fx short IMN above
SOLUTION ???
STEP 1 – BIOPSY (significant history)
NEGATIVE FOR INFECTION
NOTE ALLOGRAFT FIBULA INTRAMEDULLARY STR
B.S. signBone Stimulator
Problems?
• Metaphyseal zone
• Very rigid fixation with large moment arm
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Challenges
• Elderly
• Need immediate weightbearing
• Decreased bone stock– Osteopenia– Multiple surgeries
• Previous implant above
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1 year
LINKED CONSTRUCT
Appropriate Stability
HEALED
NO PAIN !!!
• Fracture
• Stem Loose?
• Infection?• Time since procedure?
62 yo s/p IT Fx w/ HHA, s/p 2nd fall w/ cable, s/p 3rd fall w/ pus!!!
FAL
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Leg length?
FAL
Fall #4 – Now what ???
FAL
JZ
Distal Femoral Fx 10 yrs ago w/ 4 time nonunion s/p platings
above TKR
THR above that had previous fxat stem tip
Non-ambulator x 2.5 years
INFECTED ???
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Negative Nuclear Studies
Negative ESR & CRP
ROUND 1
RESECTION ATROPHIC NU
ANTIBIOTIC PLATE
ROUND 2: Nail - Plate
Current IMN offeringCan promoteAPEX POSTERIOR:
Future Directions Distal angular options?
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2.5 months post-definitive op
Uses walker – 1st time in 2.5 yrs
Proximal and Distal N/P Linkage
CALLUS !!!LINKED Plate / NailBOTH:Proximally &Distally w/ IMN
LISS > IMNDEFORMATION W/CYCLICAL LOADING
ELASTIC
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IMN & LISSSIMILARPERMANENT DEFORMATION
PLASTIC
AXIAL LOADING:LOAD-TO-FAILURE
-IMN < LISSLOW BMD
-IMN > LISSHIGH BMD
WHERE COULD WE GO WITH THIS?
• Plate – Nail combo’s
– INTERPROSTHETIC - Fx “needing” a nail with a THR above or rev TKR below
– OSTEOPOROSIS (Chen SH, et al, Knee 2014)
– METAPHYSEAL NONUNION requiring better fixation
– AVOID DEFORMITY (Distal Femur, Proximal & Distal Tibia)
– “DIAL-IN” STABILITY
Koval KJ, Seligson D, Rosen H, Fee K. J Orthop Trauma. 1995;9(4):285-91. Distal femoral nonunion: treatment with a retrograde inserted locked intramedullary Nail
•25% union rate of nonunions with retrograde IMN alone
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Short Segment Interprosthetic& Involving Cup side
Femur Subsidence & Acetabular Failure
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71 yo Male, 11/2017
• HPI: – THA 5 yrs ago,
– Revision THA 2 years ago,
– Fixation greater trochanter 6 months ago,
– Fall 2 months ago and told, “cup moved a little, wait it out
G.T. Fx & Acetabular Failure
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Technique
Use of an "antibiotic plate" for infected periprosthetic fracture in total hip arthroplasty.Liporace FA, Yoon RS, Frank MA, Gaines RJ, Maurer JP, Polishchuk DL, Choung EW.J Orthop Trauma. 2012 Mar;26(3):e18-23
Check the Leg Lengths
2 MONTHS LATER…PLANNING STAGED TREATMENT
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MJ
• 82 yo female– 4 yr prior TEA
– “chronic suppressive abx” for 2.5 years
– Fractured 1 year prior in splint
– “multiple joint arm” on presentation
• PMH: HTN, CAD, Schizophrenia
MJ – 85 yo F