CommentaryFrom OT Europe

Periprosthetic fractures present an increasing burden, several challenges

As more patients each year undergo total joint replacement, an increasing number of patients develop periprosthetic fractures, especially femoral and proximal tibial periprosthetic fractures, and are referred to orthopaedic clinics. In the future, the numbers of patients with periprosthetic fractures following TJR procedures is expected to increase even more due to patients’ demands for an active lifestyle after they undergo TJR and due to the ever-larger overall pool of patients with a TJR.

Being involved in lower limb joint replacement for nearly 4 decades, I have noticed periprosthetic femoral fractures are increasing in number and complexity. The Vancouver classification of periprosthetic hip fractures is a logical classification system to guide treatment strategies. However, after the fracture has been appropriately classified, several complex situations may occur.

Per Kjaersgaard-Andersen, MD
Per Kjaersgaard-Andersen

Initially, what can be done to reduce numbers of fractures, particularly around lower limb TJRs, must be considered. It is easy to demand that patients “take it easy” and not perform excessive activities once they undergo TJR. However, among the claims of modern total hip arthroplasty and what is stated in information provided to patients at THA units is that after the initial follow-up period, patients can live a “normal” life without any restriction in their daily activities. This, to me, is basically the wrong kind of information to give patients. Some patients will take note of this and perform activities that heavily load their new joint and put them at increased risk for dislocation and periprosthetic fractures. Of course, many patients will be more careful and not put themselves in such a precarious situation with their newly replaced joint.

Inform patients of risk

As surgeons, it is our responsibility to inform and instruct patients about what a “careful” lifestyle with a replaced joint involves. Furthermore, we should tell patients about the possibility that a periprosthetic fracture may occur following TJR. Patients must be fully informed about the activities that may be associated with an increased risk of periprosthetic fracture. They also need to understand that someone whose THA or total knee arthroplasty is revised due to a periprosthetic femoral or proximal tibial fracture rarely returns to the same level of activity and quality of life they had after their index TJR.

In addition, although they may be nicely classified with radiographic and CT studies, these fractures are rarely “a piece of the cake” to fix. If it is a simple fracture, it may easily be treated by a trauma or a joint replacement surgeon. However, complex fractures require treatment by a surgeon with extensive experience or by a multidisciplinary team that includes both trauma and joint replacement surgeons.

Uncemented hip stems and fracture risk

It is difficult to understand why TJR surgeons worldwide still thoughtlessly use non-cemented hip stems in all their cases without consideration of the patient’s age. This practice continues even though several hip arthroplasty registries have clearly shown an association between the use of non-cemented femoral stems in elderly patients and increased incidence of early periprosthetic femoral fractures in this age group.

Uncemented stems used in elderly patients is risk factor for periprosthetic fractures. Furthermore, cementless THA is always a more expensive treatment than THA performed with a cemented stem. Thus, there is a real dilemma concerning bone cement. Some would claim that cemented stems used in elderly patients significantly increase the risk of pulmonary embolism (PE) and sudden death. I, for one, still await the results of good clinical trials and systematic reviews that prove this is the case and provide some insight into the extent that PE and sudden death occur in elderly patients after THA vs. periprosthetic fractures.

I hope good discussions result from the information raised in this article. I cannot stress enough that there needs to be an intense focus on periprosthetic joint fractures, particularly in light of the increasing worldwide burden of these fractures that is predicted.

Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.

As more patients each year undergo total joint replacement, an increasing number of patients develop periprosthetic fractures, especially femoral and proximal tibial periprosthetic fractures, and are referred to orthopaedic clinics. In the future, the numbers of patients with periprosthetic fractures following TJR procedures is expected to increase even more due to patients’ demands for an active lifestyle after they undergo TJR and due to the ever-larger overall pool of patients with a TJR.

Being involved in lower limb joint replacement for nearly 4 decades, I have noticed periprosthetic femoral fractures are increasing in number and complexity. The Vancouver classification of periprosthetic hip fractures is a logical classification system to guide treatment strategies. However, after the fracture has been appropriately classified, several complex situations may occur.

Per Kjaersgaard-Andersen, MD
Per Kjaersgaard-Andersen

Initially, what can be done to reduce numbers of fractures, particularly around lower limb TJRs, must be considered. It is easy to demand that patients “take it easy” and not perform excessive activities once they undergo TJR. However, among the claims of modern total hip arthroplasty and what is stated in information provided to patients at THA units is that after the initial follow-up period, patients can live a “normal” life without any restriction in their daily activities. This, to me, is basically the wrong kind of information to give patients. Some patients will take note of this and perform activities that heavily load their new joint and put them at increased risk for dislocation and periprosthetic fractures. Of course, many patients will be more careful and not put themselves in such a precarious situation with their newly replaced joint.

Inform patients of risk

As surgeons, it is our responsibility to inform and instruct patients about what a “careful” lifestyle with a replaced joint involves. Furthermore, we should tell patients about the possibility that a periprosthetic fracture may occur following TJR. Patients must be fully informed about the activities that may be associated with an increased risk of periprosthetic fracture. They also need to understand that someone whose THA or total knee arthroplasty is revised due to a periprosthetic femoral or proximal tibial fracture rarely returns to the same level of activity and quality of life they had after their index TJR.

In addition, although they may be nicely classified with radiographic and CT studies, these fractures are rarely “a piece of the cake” to fix. If it is a simple fracture, it may easily be treated by a trauma or a joint replacement surgeon. However, complex fractures require treatment by a surgeon with extensive experience or by a multidisciplinary team that includes both trauma and joint replacement surgeons.

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Uncemented hip stems and fracture risk

It is difficult to understand why TJR surgeons worldwide still thoughtlessly use non-cemented hip stems in all their cases without consideration of the patient’s age. This practice continues even though several hip arthroplasty registries have clearly shown an association between the use of non-cemented femoral stems in elderly patients and increased incidence of early periprosthetic femoral fractures in this age group.

Uncemented stems used in elderly patients is risk factor for periprosthetic fractures. Furthermore, cementless THA is always a more expensive treatment than THA performed with a cemented stem. Thus, there is a real dilemma concerning bone cement. Some would claim that cemented stems used in elderly patients significantly increase the risk of pulmonary embolism (PE) and sudden death. I, for one, still await the results of good clinical trials and systematic reviews that prove this is the case and provide some insight into the extent that PE and sudden death occur in elderly patients after THA vs. periprosthetic fractures.

I hope good discussions result from the information raised in this article. I cannot stress enough that there needs to be an intense focus on periprosthetic joint fractures, particularly in light of the increasing worldwide burden of these fractures that is predicted.

Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.