Fixation of Fractures Around Unstable Hip Implants

Abstract

As the rate of total hip replacement has escalated so has the rate of periprosthetic fractures, now reported to range between 0.1% and 18%. Typical periprosthetic fractures occur in older patients after low-energy falls, often in the context of osteoporosis and loose implants. Prevention and prophylaxis is the best approach but when a fracture occurs, Vancouver B2 fractures have typically showed better results with revision surgery compared with fixation, with reoperation rates reported from 18% to 33% with fixation. Although revision is presently accepted as the standard of care when the prosthetic stem is deemed loose or unstable, we propose that in frail, severely comorbid or debilitated geriatric patients with limited ambulatory status at baseline, urgent treatment with fixation to restore the stability of the preexisting implant may be an option. We propose that in analogy to the debilitated hip fracture patient, this patient population may benefit from prompt surgery within 24 to 48 hours with a goal of restoring stability and early mobilization. The lateral approach to the femur allows complete access to the bony anatomy and provides an extensile approach to the hip. Once the vastus is elevated, the fracture can easily be identified, explored, and implant stability can be assessed under direct visualization. If implant stability can be restored with anatomic reduction, the fracture can then be fixed with absolute stability technique around the stem. If comminution is present distal to the stem, relative stability technique can be used by bridging with a long lateral plate. If implant stability cannot be restored, revision remains an option. We propose that a shared decision process for fixation versus revision be done on a patient-by-patient basis. This process should include the patient, family, and surgeon and involve a frank assessment of patient needs and expectations, particularly in the frail patient with limited preexisting mobility.