Revision arthroplasty around the hip and the knee

Revision arthroplasty around the hip and the knee Plenary – case-based Periprosthetic Fractures Periprosthetic Fracture Management

Learning objectives for the cases • • Classify the fracture Describe the options and indications for nonoperative, fixation, and revision treatment Select an appropriate treatment Identify and address potential complications

Case 1: Case description • • • An 81 -year-old woman Cementless total hip arthroplasty (THA) 12 years before No problems with ambulation Fell down at home Not able to walk, she had pain • Further investigations?

Case 1 • • Classify B 1 (B 2–B 3? )

Case 1 The stem was described as stable (B 1)—fixation by cables Comments?

Case 1 2 months later, pain during weight bearing What to do?

Case 1 Plate with screw and cables Comments?

Case 1 3 months later Options?

Case 1 Revision stem, preventive cable

Case 1 3 years later

Case 1: Take-home messages • • • Complete imaging is essential Use stable and correct fixation techniques Be careful when evaluating B 1 fractures

Case 2: Case description • • A 78 -year-old patient, body mass index: 36, total knee arthroplasty (TKA) 6 years ago Complications: infection, 2 -stage revision performed, reimplantation in August 2013, cultures negative Has never been satisfied, walked with crutches Fell from bike last year, unable to walk Flexion 110°, extensor apparatus intact Global instability +, functional impairment ++ Pain Visual Analog Scale (VAS) 4 at rest and 8 after activity Lab/aspiration negative

Case 2

Case 2 • • Distal femoral fracture Classification? Instable implant, loosening of femoral component Poor host bone in distal femur Osteolysis of femoral and tibial side Osteopenia Ligament instability

Case 2 15

Case 2 Management options: • Revision TKA? • Distal femoral replacement? • Fracture stabilization? • Other considerations?

Case 2 Distal femoral replacement: • Relatively easy operation, full weight bearing allowed postoperative • Resection distal femur, poor host bone • Tibial revision with cemented stem and tibial augmentation

Case 2: Take-home messages • Difficult periprosthetic fractures can be managed by excision of the fracture fragments and replacement with tumor-type prostheses • Although providing more rapid recovery, the next operation should be considered

Case 3: Case description • • • 65 -year-old woman Painful restriction of left knee movements Moderate OA—x-rays of total knee arthroplasty (TKA)

Case 3 • • Two years later after a fall from a height Painful restriction of left knee movements • Variables—decision making? A. B. C. D. E. Bone quality. . osteopenia Level of fracture Classification Age—patient needs Type of TKA implant

Case 3 • 2 years later after a fall from a height • What next. . . A. B. C. D. E. Conventional revision TKA Lateral plate fixation +/- graft Lateral and medial plate fixation =/- graft Brace Tumor prosthesis revision TKA

Case 3 • • Plate fixation—minimally invasive plate osteosynthesis—biological fixation? Bone defect? A. Graft B. No graft Quality of fixation? A. Good B. Bad Medial buttress? A. Yes B. No

Case 3 • • No signs of union Next step? A. Conventional revision TKA B. Revision of lateral plate fixation +/- graft C. Revision of lateral and medial plate fixation +/- graft D. Brace E. Tumor prosthesis revision TKA

Case 3 • Next step? • • Mechanical or biological problem? Fixation alteration Bone grafting plus eptotermin alfa Quality of fixation No signs of union Fixation failure. . . Next step?

Case 3 • Next step? A. Conventional revision TKA B. Revision of lateral plate fixation +/- graft C. Revision of lateral and medial plate fixation +/- graft D. Brace E. Tumor prosthesis revision TKA

Case 3 • Tumor prosthesis • 7 years later satisfactory result What went wrong? A. Violation of principles B. Unstable implant C. Unstable fixation D. Poor local biology E. All of the above • Fracture fixation and adult reconstructive skills

Case 3: Take-home messages • Be aware of the unexpected and be prepared to react