Older patients with periprosthetic fractures require additional treatment, careful implant selection
ISTANBUL — Successful outcomes include factors such as, early patient mobilization, minimally invasive surgery, angular stable plating and geriatric care for older patients, according to a presenter at the EFORT Congress.
Elderly patients with periprosthetic femur fractures undergoing osteosynthesis can challenge surgeons regarding implant choice and treatment modality.
"I can say periprosthetic fractures are a surgical challenge in nearly all regions now," not just in the lower limb, Norbert P. Haas, MD, director of the Center for Musculoskeletal Surgery at the University Hospital Charité in Berlin, said in his presentation. "Exact preoperative analysis is very important, [as is] the correct classification of fracture location, the stability of the implant and the bone quality."
Norbert P. Haas
Haas stressed the importance of the right procedure for the right patient, which he said starts with fracture classification. In his institution, he uses the Vancouver Classification for proximal femur fractures and the Su Classification for distal femur fractures.
"You have to perform an osteosynthesis in all three types of fracture using the Su Classification," Haas said. "But the prosthesis must be stable; otherwise you have to perform a revision arthroplasty."
"The implant must restore and maintain the correct axis, length and rotation, because most patients are elderly. It must allow a maximum of weight bearing because many of these patients cannot use crutches anymore," he added.
As these patients are more prone to problems, Haas recommended geriatric care involvement as soon as possible. Patients should be mobilized soon after surgery using minimally invasive surgery with as little soft tissue damage as possible. Using angular stable plating one can provide higher stability in osteoporotic bone and a decrease in the secondary loss of reduction.
"Beside the plate osteosynthesis, fractures at the distal femur around a knee prosthesis with an open box design have a retrograde nailing procedure as an additional option for fracture stabilization, but only if the prosthesis is stable," Haas said. "Nevertheless, in our hands the angular stable osteosynthesis in this region is the best solution. If the prosthesis is not stable, revision arthroplasty is indicated."
For fractures around the hip, Haas said a Vancouver AG fracture can be fixed with cerclage wires and a hook plate. Vancouver B1 fractures are fixed with an angular stable plate and cerclage wires, while a Vancouver C fracture can be fixed with an angular stable plate. He said distal femur fractures for Su type I and type II fractures are fixed with an angular stable plate and a nail in open box prosthesis. Type III fractures are fixed with an angular stable plate.
Haas NP. Influence of fracture type for the choice of osteosynthesis in periprosthetic femur fractures. Presented at: EFORT Congress. 5-8 June, 2013; Istanbul.
Disclosure: Haas has no relevant financial disclosures.