Protesnära fraktur. Per Wretenberg

Transkript

1 Protesnära fraktur Per Wretenberg

2 Problemet

3 Historik Första beskrivningen 1954 Artificial hip prosthesis in acute and non-union Fractures of femoral neck Horwitz et al. JAMA 155;

4 Historik Traktionsbehandling, 3 månaders balanserat sträck The healing of human fractures in contact with acrylic cement Charnley J. Clin Othop 47; , 1966

5 Incidence 1-2% after primary THR (increasing) 4-20% after revision THR Kavanagh, JBJS (Br) 2002

6 Incidence 0.1 1% after Cemented THR Kavanagh, Clin Orthop North Am, % after uncemenetd THR Berry, Clin Orthop, 2009

7 Incidence Totala incidensen ökar något. Lindahl H, The periphrostetic femur fracture 2006 (Thesis)

8 Periprostetsik fraktur Intraoperativt jämfört med cementerad primärplastik - större risk vid ocementerad protes - större risk efter revisionevisioner - större risk vid benpackning? Postoperative - trauma - osteolysis - tumör

9 Postop. rtg Problem?

10

11 Reoperation 5 dagar senare

12 Riskfaktorer Lös protes Kvinnor Metabola bensjukdomar Osteoporos RA Preoperativ deformering av femur Ocementerad protes

13 Vancouver classification Type A: Trochanteric fractures Type B: Fracture at stem level or just under the stem Type C: Fracture distal to the stem

14 Type B fracture B1: Stable prosthesis B2: Loose prosthesis, good bone B3: Loose prosthesis, bad bone

15 Vancouver classification A = Type A B = Type B1 C = Type B2 D = Type B3 E = Type C

16 Bone defects Endolink classification

17 Vancouver classification reliability Reliable classification, Brady et al J Arthroplasty vol. 15(1) 2000

18 Vancouver classification reliability Intra-observer k-value 0.77 Inter-observer k-value 0.64 K-value = slight agreement = fair = moderate = substantial > 0.80 = almost perfect

19 Treatment of periprosthetic fractures Nonoperativ Traction Orthosis None» No adequate studies performed

20 Treatment Vancover A Non operative, mobilization Fixation with screws Fixation with cables Fixation with plate and screws

21 Treatment Vancover C Fixation with plate and screws Fixation with cables Fixation with nails (Fixation with screws alone)

22 Female 72-years Vancover C

23

24 Treatment Vancover B1 Cables (prox undisplaced fracture) Plate and screw, and or cables Mennen plate Strut graft with or without plate Strut graft and bone packing Revision THA

25 Platefixation Good/exact reposition possible Early mobilisation Partial (or full) weight bearing + Risk of devsacularisation Bone resorption under plate Cement influenced by screws? Plate fracture Non union! -

26 Technique Good exposure of fracture site needed Reduction and preliminary fixation Plate adjustment Combination of screws, angular stable screws and cables With angular stable plates, less invasive technique is possible.

27 74 year male, Vancover B1 Bra funktion efter 9 år

28 73-year male, Vancover B1 1 month postop 10 years postop

29 63-year female, Vancover B1, op 1994 New x-rays from Irak, 2010, Good function

30 79-year female, Vancover B1

31 4 months postop. 8 years postop

32 42-year male, previous acetabular fracture. Vancover B1

33

34 Vinkelstabil platta Vancover B1

35 94-årig kvinna, Vancover B1

36 Platefixation Mont et al J Arthroplasty vol 9(5) 1994 Review of litterature patients, 26 articles Plate fixation not as good as revision arthroplasty

37 I USA har det varit mycket vanligt med kombination platta-allograft, nu visar dom bra resultat med bara platta

38 Vinkelstabila plattor fungerer

39 Mennen plate Not ment for rigid fixation Space between plate and bone to not disturbe cirkulation Results?

40 Mennen plate

41

42 Cortical onlay strut allografts

43 Cortical onlay strut allografts + Good stability Stimulate fracture healing Can be incorporated in host bone and increase bone mass Create less stress-shielding than plates - Expensive, hard to get Reduced strength of graft after 4-6 months Initial weigh bearing not recommended

44 Technique Chandler et al JBJS 79A(9) 2012, from instructional course lecture AAOS Femur allograft best Divide allograft in two halves Place allograft not less than 10 cm distal to the fracture site 4 cables on each side of the fracture Place bone graft from host at the fracture site Full weight bearing after 3 months

45 Cortical allografts, results Haddad et al JBJS 84A(6) 2002 Multicenterstudy (4 centra) 40 patients op Prosthesis well fixed, no need for revision 19 patients treated with only 1 strut allograft 21 patients treated with 1 or 2 allografts and plate 27 hips revised earlier Reduced weight bearing 3 moths

46 Haddad et al, Follow-up 6-78 months (mean 28 months) 39 of 40 fractures healed radiograficaly

47 Treatment Vancover B2, B3 Revision THA

48 When the prosthesis is loose, revision is necessary

49 The problem How do we know that the prosthesis is loose? Exposure!

50 Revision of prosthesis Options 1. Cemented revision 2. Uncemented revision

51 Revision of prosthesis Cemented revision 1. Option for older patients with less physical demand 2. Option for patients with pathological fracture 3. Good and stable reposition of the fracture must be possible before cementing the prosthesis in place. 4. Long stem needed to bypass the fracture

52 Revision of prosthesis Uncemented revision with distal fixation 1. Younger patients with higher physical demands 2. Complex fractures

53 55-year male, Vancover B2 Cemented revision with long stem

54 55-year female, Vancover B2

55 Postop 5 years postop

56 75-year male, Vancover B2 Wagner

57 Postop 10 yeras postop

58 84-year male, Vancover B3 4 years post op.

59 Male 67-years, Vancover B2

60 MP-Link 1 year postop

61 59-year female, Vancover B2 MP-Link

62 Female, 55-years, Vancover B1??

63 3 months later

64 MP-Link reconstruction

65 After 1 year New bone formation

66 Male, 47 years, Vancover B2

67 MP-Link reconstruction

68 MP-technique for fracture cases Exposure easy proximal, additional osteotomy could be done Distal cement must be extracted Prophylactic cables distally Positioning of stem and trial reduction could be done without reduction of the proximal fragments Proximal fragments fixed with cables around stem

69 Resultat

70 Slutsatser 1. Majoriteten av patienter som fick en periprostetisk fraktur hade redan en lös stam. 2. Implantat relaterade faktorer finns med överrisk för Charnley och Exeter stammar av de cementerade. 3. Generellt dåliga resultat efter op. oavsett metod. Hög reoperations frekvens och många komplikationer.

71 Kvinna född 1956, HIV, op 4 år sedan

72 Revision med förtur för att förhindra fraktur

73

74 Slutsatser 1. B1 frakturer hade sämst resultat troligen beroende på att stammen inte satt fast. 2. Exploration av stammen rekommenderas vid minsta tvekan om stammen är lös. Är den misstänkt lös => revidera!! 3. Mycket hög komplikationsrisk för plattfixation, troligen beroende på att många patienter med lös protes plattfixerades. 4. Fler infektioner vid plattosteosyntes än revision. Orsak? Fick revisionerna mer antibiotika?

75 83-year male, Vancover B1??

76 Male 42-years, Vancover B1??

77 Completely stable prosthesis when exposed => B1!, plate fixation possible

78 Female, 78 years. Vancover B1?

79 Completely unstable prosthesis when exposed => B2!; revision

80 Tack!!