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arthroplasty

Periprosthetic Fracture - Total Hip Arthroplasty

advanced
6 min
22 marks
6 questions
Clinical Scenario
A 78-year-old woman with a cemented THA performed 10 years ago presents after a fall at home. She has severe right hip and thigh pain with inability to weight bear. Her leg is shortened and externally rotated. She is hemodynamically stable. She takes bisphosphonates for osteoporosis. Radiographs show a fracture around the femoral stem with evidence of proximal loosening.
AP and lateral radiographs showing periprosthetic femoral fracture at the level of the femoral stem tip. Fracture is displaced with varus angulation. Assess stem fixation status (radiolucent lines, subsidence) and cement mantle integrity.
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AP and lateral radiographs showing periprosthetic femoral fracture at the level of the femoral stem tip. Fracture is displaced with varus angulation. Assess stem fixation status (radiolucent lines, subsidence) and cement mantle integrity.

Image source: Open Access medical literature (NIH/PubMed Central) • CC-BY License

Questions

Question 1 (4 marks)

Describe the Vancouver classification for periprosthetic hip fractures and its treatment implications.

Question 2 (3 marks)

How do you determine preoperatively and intraoperatively whether the stem is well-fixed or loose?

Question 3 (4 marks)

This patient has a Vancouver B2 fracture. What are your surgical options?

Question 4 (4 marks)

Describe the Extended Trochanteric Osteotomy (ETO) technique and its indications.

Question 5 (4 marks)

What are the surgical principles for treating a Vancouver B1 fracture?

Question 6 (3 marks)

What outcomes and complications should be discussed with the patient?

Exam Day Cheat Sheet

Must Mention

  • •Vancouver classification: A (troch), B1/B2/B3 (around stem), C (below)
  • •B1 = stable stem → ORIF with cables + plate
  • •B2 = loose stem → revision with long stem
  • •B3 = loose + poor bone → revision + reconstruction
  • •Extended trochanteric osteotomy (ETO) for cement/stem removal
  • •Stem must bypass fracture by 2 cortical diameters
  • •Compare to prior radiographs for loosening

Common Pitfalls

  • •ORIF for loose stem (B2) - will fail
  • •Not checking prior X-rays for loosening
  • •Cemented revision through fracture
  • •Inadequate stem bypass distance
  • •Not excluding infection