Title: Kyle F. Dickson, M.D. M.B.A.
1Kyle F. Dickson, M.D. M.B.A.
Professor Baylor College of Medicine Southwest
Orthopaedic Group, Houston, Texas
2Place of Revision Joint Replacement
- Kyle Dickson MD, MBA
- Professor Baylor College of Medicine
- Southwest Orthopaedic Group, Houston Texas
3Arthroplasty
Trauma
4Peri-prosthetic Epidemic??
- Increasing incidence
- Prevalence arthroplasty
- Graying of America
- Increased lifespan
- 1 rising diagnosis peri-prosthetic femur
fracture (OTA, 2003)
5Challenges in Osteoporosis
- Reduction reduction clamps or reduction screws
pull out - Loss of reduction due to hardware failure
- Sick and higher mortaliy
- Soft tissue concerns
6Hip Fracture PATIENT Outcome Predictors
- Pre-injury physical cognitive status
- Ability to visit a friend or go shopping
- Presence of home companion
- Postoperative ambulation
- Postoperative complications (Cedar,
Thorngren, Parker, others)
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15Treatment Goals
- Restore axial alignment and length
- Stable fixation
- ROM as soon as possible
- Maintain fracture enviroment suitable for boney
healing - Return to pre-injury mobility
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- Op treatment best accomplishes these goals
16Classification
- Undisplaced fracture
- Prosthesis intact
Type I Type II Type III
- Displaced fracture
- Prosthesis intact
- Displaced or Undisplaced fracture
- Prosthesis loose
Lewis and Rorabeck (1997)
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18VP
- 50 yo MVA femur fx
- EtoH
- 1pk/day tobacco
- Insulin dependent diabetic
- gt20 yo hip fracture with increasing hip pain
seeking medical intervention
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26Treatment Options (type?)
- Anterior plating conventional vs locked (leave
DHS)? - Plating (remove DHS)?
- IM nail ante vs retro (remove DHS)?
- THA and plate?
- Other options?
27Biomechanical Evaluation of the LISS, Angled
Blade Plate, and the Retrograde Intramedullary
Nail for the Fixation of Distal Femur Fractutres
An Osteoporotic Cadaveric ModelKregor OTA 2002
- Osteoporotic cadaveric femuri (age 70 yo)
- Tested to failure in axial loading and torsion
- Axial loading 34 higher load for LISS Vs blade
plate and 24 higher than IMN - Loss of distal fixation with CBP and IMN
- Plastic deformation with LISS and no loss of
distal fixation - Torsion strength same for CBP, but higher for IMN
28Evolution
Or something completely different?
You be the judge!
29Any other studies?
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33Treatment
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41Plating Technique?
42Comments?
- Type of plate?
- gt300 LISS no hardware failures 2 surgeon errors
- gt50 locking condylar 7 hardware failures (surgeon
error?)
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49FU 1 1/2 yr
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55Periprosthetic Fracture
58 y.o. female s/p multiple revisions R THA low
energy fall
56Periprosthetic Fracture
-ORIF articular component - CR LISS plate shaft
- circlage cable prosthesis
57Periprosthetic Fracture
58Case
- 64 yo with no real pain prior to a fall
- Previous hip surgery for AVN 20 years ago
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60Questions
61Options
- Revise both cup and stem?
- Cerclage fractures around stem with a plate?
- Revise just the femur to long stem implant with
cerclage wires? - Revise femur and use plate (type?)?
- Other tests?
62Case
- Elevated C-reactive protein and ESR (wbc nl)
staged removal and cultures and traction (cement
spacer?) - Scanogram bilaterally
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69The Problem
Distal Fixation
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73Treatment Options
- Retrograde intramedullary nail
- Conventional plating (blade plate)
- Locked plating
- Revision with stemmed prosthesis, allograft, or
tumor prosthesis
74Biology and BonePreserve the periosteum
- Evolution
- DCP
- Large footprint, frictioned to bone
- LCDCP
- Smaller footprint, still frictioned to bone
- LCP
- Point contact with bone, no frictioning
75Direct Reduction
- fracture manipulated with bone-holding forceps or
levers - negative biologic impact
Choke Kill
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7715 months post-op
7877 yo F with femur nonunion
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80Retrograde Nailing
- Is the notch open or closed?
- If open, is it large enough?
- Narrow notch and closed box seen in posterior
stabilized knees
81Summary - Nails
- Know the characteristics of the nail you use
- Consider curve mismatch
- Avoid anterior cortex impingement
- Consider longer nails than shorter
- Consider Locking distally
- Pending data!
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82Retrograde Intra-medullary Nail
- Nail size canal diameter mismatch
- Must have two interlocking screws distally
83Constrained Rotating Hinge
84Constraint Comes at a Price!!
Peri-prosthetic fracture
Non union and broken plate
85Inter-Device Distance (IDD)
lt12cm
86Interprosthetic Fractures
- Similar principles
- Overlap stems when present
- Avoid retrograde nail
- Stress concentration between nail and THA
- LISS for distal fractures
87Summary
- If prosthesis is looseRevise it
- If bone is missing.Graft it or strut it
- If prosthesis is stable...Fix the fracture
- Strut grafts not necessary
- Locked plates are better than standard plates
- Locked plates better than retrograde nails
- Splint the entire bone..the longer the better
- Overlapdont gap!
88Summary - patient
- Periprosthetic fracture are a growing epidemic
- Fractures are difficult manage
- Patients may be difficult to manage
- Team approach
- Consider functional goals for patient
- Consider skill of the surgeon
89Summary screws and surgery
- Screws better than wires
- Locked screws better than standard screws
- Bicortical locked screws better than unicortical
locked screws - Use indirect reduction techniques
- Use biologic, atraumatic surgery
90Conclusion
- Periprosthetic fracture are a growing epidemic
- Difficult management
- Locked plates helpful
- Maintain principles of fracture management
91Thank You