periprosthetic hip fractures
A 64-year-old patient with rheumatoid arthritis and seizure disorder presents to you for evaluation of a painful, dislocating LEFT total hip replacement. She reports that 3 days after her initial surgery performed 6 months prior, she fell due to a seizure and sustained a fracture dislocation of the hip. Her initial surgeon opted to treat this with closed reduction and observation for a greater trochanteric fracture. You were in the process of obtaining further operative reports and investigations while the patient was an outpatient. However, the patient had another fall and presented to the emergency department with inability to ambulate due to RIGHT hip pain. She underwent RIGHT total hip replacement 8 years prior and the hip was asymptomatic until the injury. Figure 7–19A reveals her pelvic x-ray at her first visit with you for evaluation of the left hip. Figure 7–19B is a pelvic x-ray performed in the ED after she fell onto the right hip.
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Figure 7–19 A–B
What is the next best step in the course of this patients’ treatment?
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DEXA bone density test
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MRI
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Judet views
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Bone scan
Discussion
The correct answer is (C). The patient has sustained a periprosthetic acetabular fracture. Judet views should be performed in order to further evaluate the fracture pattern.
What is the best treatment approach for this fracture?
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Closed reduction and functional bracing
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Open reduction and internal fixation with retention of the current components
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Open reduction and internal fixation and revision of the femoral component only
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Open reduction and internal fixation and revision of the acetabular component only
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Open reduction and internal fixation and revision of both components
Discussion
The correct answer is (D). The films reveal a displaced periprosthetic acetabular fracture in which the acetabular component is unstable/loose. The fracture pattern is an anterior column fracture with a posterior hemitransverse fracture. This required removal of the loose acetabular component, anterior and posterior plate fixation, and revision of the acetabular component.
Helpful Tip:
Situations which are radiographically unclear whether an implant is loose in the setting of periprosthetic fracture, history taking can be very informative. In periprosthetic fractures of the femur, a history of “start-up” pain which occurred in the thigh upon getting up from a seated position that predates the traumatic event is suggestive of femoral loosening. In acute periprosthetic acetabular fractures, a history of prior groin or buttock pain can be suggestive of pre-existing acetabular cup loosening that was present at the time of the fall.
Objectives: Did you learn...?
Identify and classify periprosthetic hip fractures?
Recognize the appropriate treatment strategies for periprosthetic fractures based upon fracture pattern and stability of the components?