Introduction

Periprosthetic femoral fracture is a difficult surgical problem for orthopedic surgeons. It can happen during or after the operation. The ever-expanding indications for total hip arthroplasty are leading to more implants being placed in younger as well as in older patients with high functional demand. Also, prolonged life expectancy is contributing to an overall increment of periprosthetic femoral fractures. The incidence of periprosthetic femoral fractures (PFFs) has been reported to be between 1% and 11% over a primary and up to 18% over a revised hip femoral stem (1). Management of these injuries is often resource intensive and can present significant socioeconomic challenges. Understanding the principles of surgical management these cases and recognising when fixation or replacement is required is critical (2). Risk Factors for periprosthetic femoral fractures are osteoporosis, poor bone stock, uncemented femoral stem, revision of a femoral stem, previous fracture neck of femur treated by THR, osteolysis and aseptic loosening. These fractures can occur during previous implant removal, bone preparation and placement of the revision implant. History and physical examination reveal acute onset of pain, deformity and history of a fall. PFFs occurring over a THA can be divided into intra-operative and post-operative PFFs. Intra-operative fractures are estimated to occur in less than 1% of cemented and in 5.4% of uncemented primary THA, while in revision surgery the incidence of PFFs is higher, up to 3.6% during cemented and 20.9% during uncemented procedures. (7)

In general, in the context of a well-fixed femoral stem (Vancouver B1 or C) it is possible to retain the prosthesis and treat with internal fixation methods (8). When there is concern of loosening or instability around the stem (Vancouver B2, B3) then the literature supports revision arthroplasty surgery with or without internal fixation (9).

Radiographic Evaluation is done by full-length views of the femur (AP, lateral view), AP pelvic radiograph. Judet views are done to evaluate the floor, roof, and columns of the acetabulum. CT and MRI are done to rule out unusual complexity, especially around the acetabulum. Evaluation is done to exclude the possibility of infection by Inflammatory markers and intraoperative testing is done by frozen section analysis of periprosthetic tissue. Classification of periprosthetic femoral fracture is Vancouver classification. This system is based on site of the fracture, stability of the stem and quality of bone.

Material and method

We have operated 11 cases of PPF in our hospital in last 3 years. Two fractures were Type A, seven cases were Type B and one case was Type C fractures. Type A fractures were managed by cables and stainless-steel wires. Type B fractures were managed by long plates, and Type C fracture was managed by distal femoral locking plate. Results were assessed by modified harris hip score. It was found excellent in 3 cases, good in 7 cases and fair in one patient.

Figure 1: A- Preop xray of B1 fracture, B- Post operative xray of B2 fracture

Figure 2: A- Preoperative x-ray of B2 fracture, B- Post operative x-ray

Alongside recent developments in periprosthetic technology and surgical technique, demographic ageing has greatly increased the incidence of certain patient-specific complications. As we see more patients living into their sixties and beyond, we must contend with greater incidences of age-linked comorbidities, particularly osteoporosis and cognitive decline.

So, while the former of these makes fractures both more likely and more difficult to stabilize, the latter impairs patient’s abilities either to avoid fractures or to comply with complex post-surgical therapeutic regimens. Consideration of such issues is essential to decide on the most appropriate approach for each patient. (4)

Essentially all periprosthetic fractures require some treatment. Stable nondisplaced fractures may only require protected weightbearing or cast/brace immobilization (and pain medication), but most unstable peri-implant fractures require surgical stabilization, implant replacement, or both to restore function. Surgical intervention follows the same guidelines for peri-implant fractures as for other fractures.

The goals of treatment include the following: Early ambulation, which helps avoid pulmonary complications, pressure injuries, disuse osteoporosis, and other complications of prolonged bedrest, restoration of axial alignment, which helps prevent eccentric stress on the prosthesis that leads to early loosening and stabilization of the limb, which allows joint motion and helps prevent stiffness and muscle atrophy. (5)

The aging population and the increasing number of patients with primary total hip arthroplasties (THA) has equated to an increased incidence of periprosthetic fractures (PPF) of the hip. These injuries are a significant source of patient morbidity and mortality, placing a financial burden on healthcare systems worldwide. As the volume of PPF is expected to along with the growing volume of primary and revision THA, it is important to understand the outcomes and factors associated with treatment success. (6)

Non-operative treatment of PPFs has been associated with poor outcomes (Nonunions and malunions), medical complications (10) except probably in cases of a critically ill patient unable to undergo any major surgical intervention. With the evolution of implants and further experience in revision surgery, operative intervention is nowadays the choice of treatment. More recently, new evidence related to anabolic drug therapies in combination with non-operative protocols, even for PPFs with an unstable prosthesis, has introduced an interesting alternative method for very frail patients, or those with minimally displaced fractures. (11)

The evolution of orthopaedic implants has provided us with more intraoperative surgical options and solutions to deal with these complex injuries, and that applies to both revision implants and fixation devices. The need though remains for even more specially designed implants to address if not all at least the vast majority of PPFs. New concepts of fracture fixation are here, such as plates with far cortical locking (FCL) and active plating. (12,13)