History

By definition, all patients with a periprosthetic fracture will have a previous history either of joint replacement or of internal fixation for a fracture. The term peri-implant fracture applies to periprosthetic fractures (ie, fractures around a joint replacement) while also including fractures around an orthopedic fixation device.

The patient's acute history will usually include a traumatic event (as with any nonperiprosthetic fracture) or may present more insidiously with gradual increasing pain secondary to a stress fracture around the implant. Intraoperative periprosthetic fractures may be the result of difficulty preparing for the placement of the implant (eg, overreaming the acetabulum before placing a total hip prosthesis) or difficulty placing the prosthesis (eg, a calcar fracture during implantation of the femoral component of a hip replacement when there is a mismatch between the size of the prosthesis and the area prepared for it).

Periprosthetic occult acetabular fractures are common during press-fit acetaular insertion in primary hip replacement and may not be recognized during surgery. Surgeons should have a high index of suspicion, especially in male patients who have unexplained early postoperative groin pain after cementless acetabular placement.^[40]

A prefracture history of thigh pain with weightbearing or decreased mobility at the hip (for femoral periprosthetic fractures) predicts a high likelihood that the stem is loose. A periprosthetic fracture around an uncemented prosthesis that occurs within the first few weeks of implantation should be presumed loose because of insufficient time for the stem to become integrated. This diagnosis of a loose stem is important; it may not be apparent on imaging, but it is crucial in determining classification and best treatment.^[5]

Physical Examination

The physical examination is essentially the same as for any fracture. Patients exhibit the usual signs of fracture and have a history of a previous prosthesis or implant. There is tenderness, swelling, and instability (usually) at the fracture site. There may be a limb-length discrepancy and deformity, and the patient may be unable to use the limb. The fracture can occur with minimal trauma (especially with a previously loose prosthesis or osteoporotic bone) or an obvious traumatic incident.

The examiner should check neurovascular status, evaluate for compartment syndrome, and identify any open wounds.

Differential Diagnoses

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Distal femur fracture during hip arthroplasty.
Failed fixation caused by fracture through screw holes.
Fracture around loose prosthesis treated with replacement.
Fracture at the end of implant treated with replacement.
Fracture around stable prosthesis treated with flexible rods.
Fracture around plate implant treated with rigid rod.
Fracture around stable prosthesis treated with rigid rod.
Fracture around stable prosthesis treated with standard plate.
Fracture around stable rod implant treated with plate.
Fracture around plate treated with a rod (pathologic).
Open reduction and internal fixation with 2 "combi" fixed-angle locking screw plates (anterior and lateral placement to help control both anterolateral and mediolateral forces).
Fracture around stable implant treated with less invasive stabilization system (LISS) plate.
Failed periprosthetic repair (total hip above, total knee below).
Failed periprosthetic fracture repair.
Vancouver B1 fracture treated with locked plate.
Vancouver B1 fracture at tip of well-fixed hip replacement stem.
Vancouver B1 fracture treated with locked plating technique.
Periprosthetic fracture at stem of hip replacement with insufficient proximal bone for internal fixation.
Periprosthetic fracture at stem of hip replacement with insufficient proximal bone for internal fixation; proximal femur replacement prosthesis with internal fixation.
Periprosthetic fracture.
Third periprosthetic fracture.
Third periprosthetic fracture.
Third periprosthetic fracture.
Healed third periprosthetic fracture after minimally invasive locked plating.
Healed third periprosthetic fracture after minimally invasive locked plating.
Healed third periprosthetic fracture after minimally invasive locked plating.
Healed third periprosthetic fracture after minimally invasive locked plating.
Healed third periprosthetic fracture after minimally invasive locked plating.
Example of periprosthetic fracture at tip of proximal stem of total knee replacement in elderly patient with osteoporotic bone that was treated with Ilizarov circular multiplanar thin wire external fixator with excellent outcome. Courtesy of Springer Nature [Nozaka K, Miyakoshi N, Hongo M, et al. Effectiveness of circular external fixator in periprosthetic fractures around the knee. BMC Musculoskelet Disord. 2020;21(317). Online at: https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-020-03352-9. Reused without alteration under Creative Commons Attribution 4.0 International License.]
Nonunion of distal femur periprosthetic fracture above total knee replacement. Preoperative AP radiograph for distal femur replacement. Courtesy of William J Hopkinson, MD, FACS, FAAOS.
Nonunion of distal femur periprosthetic fracture above a total knee replacement. Preoperative lateral radiograph for distal femur replacement. Courtesy of William J Hopkinson, MD, FACS, FAAOS.
Distal femur replacement after distal femur peri-implant fracture with prior plate fixation. Courtesy of William J Hopkinson, MD, FACS, FAAOS.

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Author

Steven I Rabin, MD, FAAOS Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Musculoskeletal Services, Dreyer Medical Clinic

Steven I Rabin, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Fracture Association, American Orthopaedic Association, AO Foundation, Chicago Metropolitan Trauma Society, Illinois Association of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society, Mid-America Orthopaedic Association, Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Samuel Agnew, MD, FACS Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center

Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India

Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) Professor, Department of Orthopedic Surgery, University of Texas Medical School at Houston

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Sections Periprosthetic and Peri-implant Fractures
Overview
Presentation
DDx
Workup
Treatment
Medication
Media Gallery
References

Periprosthetic and Peri-implant Fractures Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

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