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Treatment of Peri-Implant Fractures of The Femur PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Treatment of Peri-Implant Fractures of the Femur” by Steven I. Rabin.

This medical PowerPoint presentation is about peri-implant fractures of the femur which refer to fractures that occur around the site of a previously implanted prosthetic femoral component. The treatment of these fractures depends on the type and location of the fracture, as well as the stability of the implant.

In general, non-displaced fractures can be treated with non-operative measures such as immobilization in a cast or brace, non-weight bearing, and physical therapy. However, displaced fractures usually require surgical intervention.

Surgical options may include internal fixation with plates, screws, or nails, as well as revision surgery to remove and replace the prosthetic component. The choice of surgical technique depends on the location and extent of the fracture, as well as the stability of the implant.

In cases where the implant is unstable or has failed, revision surgery may be necessary to replace the implant with a new one. The type of implant used may depend on several factors, including the patients age, level of activity, bone quality, and overall health.

It is important to note that the treatment of peri-implant fractures of the femur can be challenging and often requires specialized care from an experienced orthopedic surgeon. A thorough evaluation and individualized treatment plan should be developed for each patient.

Tags : Peri-Implant Fractures of the Femur, non-displaced fractures, Orthopaedic Surgery, Orthopaedic Surgery PowerPoint presentation

Published on : Jun 23, 2023 | Views : 1132 | Downloads : 0

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Slide 1-

Treatment of Peri-Implant Fractures of the Femur Steven I. Rabin Dreyer Medical Clinic
Slide 2-

Fractures around Implants Pose Unique Fixation Challenges
Slide 3-

Number of Implants in the Femur are Increasing Population is Aging Joint Replacement - Indicated More Often Fracture Fixation - Indicated More Often
Slide 4-

Increasing Number of Implants in the Femur Over 123,000 Total Hip Replacements Over 150,000 Total Knee Replacement each year in the United States Numbers Expected To Increase with Aging Population
Slide 5-

Increasing Number of Implants in the Femur Over 300,000 Hip Fractures each year in the United States almost all are treated surgically with internal fixation or prosthetic replacement
Slide 6-

As the Number of Implants Placed Increases the Number of Associated Fractures will Increase
Slide 7-

High Mortality after Periprosthetic Hip Fracture Mortality following a periprosthetic hip fracture (89% 1-year survival) is: significantly greater than the mortality after primary total hip replacement (97% 1-year survival) in matched patients And statistically similar to the mortality following hip fractures (83.5%)
Slide 8-

Pre-Operative Planning As with all fracture fixation surgery, pre-operative planning is essential. Planning begins with classification Templating is extremely valuable Surgeon must be sure that he/she has an adequate selection of specialized implants available Including cables, special plates & screws of appropriate size and length
Slide 9-

Be Prepared! The surgeon may need to use specialized implants not usually kept “on the shelf” at his/her hospital. Examples include specialized peri-prosthetic screws, claw plates for the greater trochanter, cable systems, and broken screw/implant removal devices
Slide 10-

Classification The most commonly used classifications for periprosthetic fractures around hip replacements are the Vancouver and AAOS classifications. The most commonly used classification for periprosthetic fractures around knee replacements is the Neer classification.
Slide 11-

Vancouver Classification of Periprosthetic Hip Replacement Fractures Type A: Fracture at the trochanters AL at lesser trochanter AG at greater trochanter Illustrations from Duncan CP and Masri BA: Fractures of the Femur after hip replacement. Instr Course Lect 44:293-304, 1995
Slide 12-

Vancouver Classification of Periprosthetic Hip Replacement Fractures Type B1: fracture is around or just below a well-fixed stem
Slide 13-

Vancouver Classification of Periprosthetic Hip Replacement Fractures B2 Fracture is around or just below a loose stem
Slide 14-

Vancouver Classification of Periprosthetic Hip Replacement Fractures B3 Fracture is around or just below a stem with poor proximal femoral bone stock
Slide 15-

Vancouver Classification of Periprosthetic Hip Replacement Fractures Type C Fracture Well Below the Stem
Slide 16-

AAOS Classification of PeriProsthetic Hip Fractures Level I: (Proximal to Lesser Trochanter) Type I: proximal to the intertrochanteric line Type II: vertical split above lesser trochanter Level II: (<10 cm. distal to Lesser Trochanter) Type III: Split below the lesser trochanter Level III:(>10 cm. distal to Lesser Trochanter) Type IV: Fracture at the tip of the stem. A: spiral B: short oblique or transverse Type V: Severely comminuted Type III or IV Type VI: Fracture distal to the prosthesis
Slide 17-

Neer Classification of Periprosthetic Knee Replacement Fractures Type I: Extra-articular or Non-displaced Femur Fx <5mm of displacement or > 5 degrees angulation Type II: Extra-articular Femur Fx >5mm of displacement or > 5 degrees angulation Type III: Comminuted Femur Fx. Type IV: Fractures at the Tip of Stemmed Femoral Prostheses Type V: Tibial fracture
Slide 18-

Fractures around Implants: Unique Fixation Challenges Original Placement of the Implant may predispose to later fracture Long Term Presence of the Implant may change the structure of bone and increase susceptibility of fracture Implant Itself may interfere with healing or the placement of fixation devices
Slide 19-

Peri-Implant Fractures May be Caused by Technical Problems During Implant Placement
Slide 20-

Risk Factors for Intra-operative Periprosthetic Fractures For patients with hip replacements: increased risk of periprosthetic fracture if: Press-fit implant (larger prosthesis compared to medullary canal) Long Stem implant (mis-match between stem and femoral bow) Revision Procedure (compromised bone stock) (cement removal – 44% risk of intra-operative fracture) (impaction bone grafting techniques 4-32% risk) Limited Incision technique 3% risk (poorer visualization of the anatomy)
Slide 21-

Technical Problems during Implant Placement include: Notching Anterior Femoral Cortex during Knee Replacement Cracking Calcar during Hip Replacement Penetrating Shaft during Hip Replacement Cracks between Screw Holes during Internal Fixation
Slide 22-

Notching Anterior Femoral Cortex During Knee Replacement May have 40% fracture rate at 8 years Figgie et. al. J. Arthroplasty 1990
Slide 23-

Incidence of Supracondylar Femur Fracture after Total Knee Replacement: .6 to 2.5%
Slide 24-

Fracture Associated with Implant Placement Fracture of the Femoral Neck may occur with Antegrade Intramedullary Rodding Stress Riser at Insertion Site
Slide 25-

Calcar May Fracture During Hip Arthroplasty If the prosthesis or trials are not properly sized
Slide 26-

Femoral Stem may Perforate the Femoral Shaft During Hip Replacement especially if the femur is bowed 3.5% fracture rate during Primary Total Hip Replacement Shaw & Greer, 1994
Slide 27-

Greater Trochanteric Fracture Greater Trochanteric fractures can occur during placement of a total hip prosthesis, during removal, or due to a separate traumatic injury Options for fixation include cerclage wires or a claw plate Zarin, JS, Zurakowski, D, and Burke, DW: J.Arthroplasty. 2009 Feb;24(2):272-80 Claw Plate Fixation of the Greater Trochanter in Revision Total Hip Arthroplasty
Slide 28-

The Bone Can Crack Between Screw Holes During Internal Fixation Especially in osteoporotic bone
Slide 29-

Stress Risers During Internal Fixation Any Drill Hole up to 20% of the bone’s diameter will weaken bone by 40% 90% of fractures around fixation implants occur through a drill hole Koval et. al. 1994
Slide 30-

Stress Risers During Internal Fixation Fractures Tend to Occur at the End of Implants where weaker bone meets the rigid device
Slide 31-

Fractures can occur Postoperatively Incidence of 0.6 – 2.5% of hip fractures
Slide 32-

Fractures Associated with Implant Removal During Prosthetic Revisions 17.6% fracture rate compared to 3.5% during primary hip replacements (5 times the rate for primary hip replacement) through osteoporotic bone or osteolytic defects
Slide 33-

Fractures Associated with Implant Removal Zickel IM Nails – are associated with Subtrochanteric Fractures after Removal Plates Stress Shield Cortical bone - increased rate of fractures after removal (especially forearm)
Slide 34-

Problems with Treating Peri-Implant Fractures Implants may block new fixation devices Stems, rods, and bone cement may fill the medullary canal preventing IM fixation of fractures Stems and rods may also block screw fixation through the medullary canal to hold plates on bone Implants may impair healing due to endosteal ischemia Defects in bone from Osteolysis, Osteoporosis, and Implant Motion may compromise fixation
Slide 35-

Peri-Implant Fracture Fixation Methods Follow Standard Principles of Fixation Must Achieve Stable Anatomic Fixation while Preserving Soft Tissue Attachments Indirect Reduction Techniques Careful Preoperative Planning Intra-Operative Flexibility/Creativity Choose the Device That Fits the Patient
Slide 36-

Periprosthetic Femur Fractures Treatment Options are: Long-stem revision arthroplasty Cortical strut allografting Plate fixation with screws Plate fixation with cables Intramedullary Devices
Slide 37-

Treatment Options Most Important Factor in Treating Peri-Implant Fractures is the Status of the Implant
Slide 38-

When the Implant is Loose, Mal-aligned or Deformed Consider Revision/Replacement
Slide 39-

When the Implant is Stable, and Well Aligned with Good Quality Bone Consider Fixation
Slide 40-

Implant Revision/Replacement Avoids potential difficulties of fixation does not have to avoid the implant does not require stable fixation in poor bone Avoids potential complications of malunion or nonunion Indicated if Implant is Loose, Mal-Aligned, Deformed or there is Poor Bone Quality
Slide 41-

Case Example 1: Revision of Loose Prosthesis Complicated by Fracture 82 y/o F Pre-existing LOOSE Hip Replacement Fell sustaining Peri-Prosthetic Femoral Shaft Fracture X-ray Findings: Osteolysis, Subsidence
Slide 42-

Case Example 1: Revision of Loose Prosthesis Complicated by Fracture 82 y/o F Treatment: Prosthesis Removal, Strut Medial Allograft, and Long Stem Femoral Revision Follow-up - allograft incorporated and prosthesis stable with healed fracture at 6 months
Slide 43-

Case Example 2: Hip Replacement after Fracture at Tip of DHS Implant Elderly M DHS for Intertrochanteric Hip Fracture Fixation
Slide 44-

Case Example 2: Hip Replacement after Fracture at Tip of DHS Implant Elderly M Intertrochanteric Fracture Healed Fell 1 year later sustaining Femoral Neck Fracture at tip of lag screw X-rays showed poor bone stock
Slide 45-

Case Example 2: Hip Replacement after Fracture at Tip of DHS Implant Elderly M Treatment: Hardware Removal, Hemiarthroplasty Follow-up : Functioning well at 6 months
Slide 46-

Fixation Around An Implant Avoids Difficulties of Implant Removal may be technically difficult may be time-consuming may cause further fracturing of bone Indicated if Implant is Stable, Well Aligned, and Bone Quality is Good
Slide 47-

Peri-Implant Fracture Fixation A Wide Selection of Devices Must be Available: Special Plates with Cerclage Wires Curved Plates to Match the anterior Bow of the Femur are Now Available. Flexible Intramedullary Rods Rigid Intramedullary Rods
Slide 48-

Plating Techniques for Peri-Implant Fractures Advantages of Plates: Allow Direct Fracture Reduction and Exact Anatomic Alignment Less Chance of Later Prosthetic Loosening due to Mechanical Mal-alignment Allow Interfragmentary Compression and A Rigid Construct for Early Motion
Slide 49-

Plating Techniques for Peri-Implant Fractures Disadvantages of Plates: Biologic and Mechanical Disadvantages Compared to IM devices even with Indirect Techniques Require Special Plates which accept Cerclage Wires, and/or allow Unicortical Screws and/or match the shape of the bone
Slide 50-

Case Example 3: Fracture at the Proximal End of a Supracondylar Nail Treated with a Plate Elderly F Pre-existing healed supracondylar femur fracture New fracture at end of rod after MVA Treatment: ORIF with Plate/wires Follow-up: Healed after 3 months and still asymptomatic at 2 years
Slide 51-

PeriProsthetic Fracture For Hip Peri-Prosthetic Fixation -Standard is with Plate or Allograft or
Slide 52-

Allograft Technique Picture/x-ray courtesy of Dr. John Cardea
Slide 53-

Plate Technique Advantages of Plate over Allograft Less Invasive Leaves Medial Soft Tissues Intact Avoids Potential Allograft Risks Including Donor Infection Stronger Allograft bone can be Brittle
Slide 54-

Combined Allograft Struts & Plates Mechanically the use of allograft struts and plates has been found to be stronger than plates alone (with or without locking screws) Rad Zdero, Richard Walker, James P. Waddell, and Emil H. SchemitschBiomechanical Evaluation of Periprosthetic Femoral Fracture FixationJ. Bone Joint Surg. Am., May 2008; 90: 1068 - 1077. Although this study was in vitro and so did not take into account the additional biologic trauma inherent in placing the allograft struts
Slide 55-

Recent Clinical Studies Controversial M.A. Buttaro, G. Farfalli, M. Paredes Núñez, F. Comba, and F. PiccalugaLocking Compression Plate Fixation of Vancouver Type-B1 Periprosthetic Femoral FracturesJ. Bone Joint Surg. Am., Sep 2007; 89: 1964 - 1969. Conclusion: Plate Fixation Should be Supplemented by Allograft Struts Catherine F. Kellett, Petros J. Boscainos, Anthony C. Maury, Ari Pressman, Barry Cayen, Paul Zalzal, David Backstein, and Allan GrossProximal Femoral Allograft Treatment of Vancouver Type-B3 Periprosthetic Femoral Fractures After Total Hip Arthroplasty. Surgical TechniqueJ. Bone Joint Surg. Am., Mar 2007; 89: 68 - 79. Conclusion: Allograft Struts alone are enough. Plates not necessary. William M. Ricci, Brett R. Bolhofner, Timothy Loftus, Christopher Cox, Scott Mitchell, and Joseph Borrelli, Jr.Indirect Reduction and Plate Fixation, without Grafting, for Periprosthetic Femoral Shaft Fractures About a Stable Intramedullary Implant. Surgical TechniqueJ. Bone Joint Surg. Am., Sep 2006; 88: 275 - 282. Conclusion: Plate fixation alone is enough. Struts not necessary.
Slide 56-

PeriProsthetic Fracture Plate or allograft attachment is by Cerclage Wires or unicortical screws or
Slide 57-

Plate Techniques May Use Cables to attach the plate to the bone Cables Require Extensive Exposure And are Technically Demanding So the fewer Used, the Better: To decrease operative trauma and operating time Pictures courtesy of Dr. John Cardea
Slide 58-

Plate Techniques Can Also Use Screws to Attach the Plate to Bone Screws Can be Placed Easier than Cables And Can be Placed Percutaneously with less soft tissue trauma than Cables So using Screws instead of Cables should decrease operative trauma and operating time
Slide 59-

Use of plates with cables:There are many reports Examples: -Ogden and Rendall, Orthop Trans, 1978 -Zenni, et al, Clin Orthop, 1988 -Berman and Zamarin, Orthopaedics, 1993 -Haddad, et al, Injury, 1997 But none of these address the question: how many cables are necessary?
Slide 60-

Cables: Cables resist bending loads: -Mihalko, et al, J Biomechanics, 1992 BUT Cables resist torsional loads poorly compared to screws -Schmotzer, et al, J Arthroplasty, 1996 The Use of Screws should improve Rotational Stability
Slide 61-

PeriProsthetic Fracture Cerclage Wires are Less Mechanically Sound than Unicortical Screws Lohrbach & Rabin MidAmerica Orthopedic Assoc. Annual Meeting 2002
Slide 62-

Conclusions: A unicortical screw significantly increases torsional and A-P stability and should be added to cable-plate constructs At least six cables are needed in the absence of a unicortical screw to improve A-P and rotational stability Lohrbach & Rabin MidAmerica Orthopedic Assoc. Annual Meeting 2002
Slide 63-

Case Example 4: Fracture at Distal End of Hip Replacement Stem Treated with a Standard Plate Elderly F Pre-existing Asymptomatic Hip Arthroplasty Fell out of a car sustaining fracture at tip of stem X-rays showed a solid prosthesis
Slide 64-

Case Example 4: Fracture at Distal End of Hip Replacement Stem Treated with a Standard Plate Elderly F Treatment: DCP plate w. screws/cerclage wires Follow-up: Healed/Asymptomatic at 3 years
Slide 65-

Case Example 5: Peri-Prosthetic Fracture Treated with Locking Compression Plate 73y/o M Healthy 3 previous platings
Slide 66-

Case Example 5: Peri-Prosthetic Repair with Locking Plates Treatment = Double Locked Compression Plate, electrical stimulator, Hardware removal Locking Screw Plates are Ideal because they provide stable fixed angled unicortical fixation
Slide 67-

Case Example 5: Peri-Prosthetic Repair with Locking Plates Clinically painless by 6 weeks Radiographically appeared healed at 2 months Follow-up 13 months Complication: S. epi post-op infection required I&D & e-stim removal at 3 months
Slide 68-

Case Example 6: Peri-Prosthetic Repair with LISS Plate 49 y/o F Healthy: Fracture at end of Hip Stem 3 previous platings, 1 previous retrograde rod
Slide 69-

Case Example 6: Peri-Prosthetic Repair with LISS Treatment = LISS + locking plate, electrical stimulator, bone graft (LISS – less invasive stabilization system)
Slide 70-

Case Example 6: Peri-Prosthetic Repair with LISS Follow-up 19 mo. No Pain by 2 mo. Bridging 5 mo.
Slide 71-

Case Example 7: Fracture Distal to Hip Stem Treated with Curved Locking Plate 72 y/o Male with Hip Replacement for Arthritis X-ray from Routine Annual Follow-up (6 months prior to fracture)
Slide 72-

Case 7: Treatment with Curved Plate Fracture
Slide 73-

Case 7: Curved Plate Intra-op Curved Plate Matches Bow of Femur
Slide 74-

Case 7: Curved Plate Example Healed at 6 months
Slide 75-

Flexible Intramedullary Rods(Zickel, Enders etc.) Flexible Rods Advantages: can be placed via minimal incisions act as internal splints until fracture healing
Slide 76-

Flexible Intramedullary Rods Flexible Rods Disadvantages: require external protection (cast or brace) rarely allow early motion or weight-bearing must be enough space in the medullary canal for implant and rod
Slide 77-

Case Example 8: Distal Femur Fracture w. Proximal Hip Replacement Treated with Flexible IM Rod Elderly F s/p MI Pre-existing Asymptomatic Hip Hemiarthroplasty Fall sustaining distal femur shaft fracture X-rays showed wide medullary canal and osteoporosis
Slide 78-

Case Example 8: Distal Femur Fracture w. Proximal Hip Replacement Treated with Flexible IM rod Elderly F s/p MI Treatment: Zickel Supracondylar Device Follow-up: Healed Asymptomatic at 3yrs
Slide 79-

Rigid Intramedullary Rods(Antegrade, Supracondylar, Retrograde) Rigid Rod Advantages: Do Not Require External Support Provide Rigid Fixation Biologic & Mechanical Advantages of Intramedullary Position
Slide 80-

Rigid Intramedullary Rods Rigid Rod Disadvantages: Cannot be used with a pre-existing stemmed implant
Slide 81-

Case Example 9: Fracture at the End of a Blade Plate Treated with a Retrograde Nail Young M 2 yrs after healed subtrochanteric hip fracture with retained blade plate In a High Speed Motor Vehicle Accident, sustained a fracture at the distal end of the plate
Slide 82-

Case Example 9: Fracture at the End of a Blade Plate Treated with a Retrograde Nail Young M 2 yrs after healed subtrochanteric hip fracture with retained blade plate Treatment: Retrograde Rodding Follow-up: at 2 years healed and asymptomatic
Slide 83-

Case Example 10: Fracture Above a Total Knee Replacement Treated w. an Antegrade Nail Elderly F Bilateral Knee Replacements Sustained Bilateral Distal Femur Fractures Proximal to Knee Replacements after MVA
Slide 84-

Case Example 10: Fracture Above a Total Knee Replacement Treated w. an Antegrade Nail Elderly F Bilateral Knee Replacements Treatment: Bilateral Antegrade Rodding Follow-up: at 3 years: Fractures healed and both knees asymptomatic
Slide 85-

Summary If the prosthesis or implant is Loose, or Bone Quality is Poor - then the implant should be revised while fixing the fracture If the prosthesis or implant is Stable and Bone Quality is Adequate for Fixation - then the implant should be retained while the fracture is fixed following standard principles
Slide 86-

Remember: If Fixation is chosen: Follow Principles of Good Fracture Care
Slide 87-

Case Example 11: Revision of Fixation Requiring Osteotomy 78 y/o Female: X-rays from 7 years ago after treatment of infected intertrochanteric nonunion Asymptomatic in interim
Slide 88-

Example 11: Revision of Fixation Femoral Neck Fracture (Vertical Shear Pattern)
Slide 89-

Example 11: Revision of Fixation Fixation of fracture with Valgus Intertrochanteric Osteotomy restores leg length and converts shear forces across the femoral neck fracture into compressive forces
Slide 90-

Example 11: Revision of Fixation Healing at 3 months: (Plans to shorten blade)
Slide 91-

Warning! The Bone Quality Must be Adequate to Hold Fixation in addition to Stability of the Implant if Fixation is chosen instead of revision/replacement.
Slide 92-

Example 12: Stable Prosthesis But Poor Bone Quality 90 year old Female with asymptomatic Hemi-arthroplasty at annual follow-up
Slide 93-

Example 12: Stable Prosthesis But Poor Bone Quality Fracture 2 months later
Slide 94-

Example 12: Stable Prosthesis But Poor Bone Quality Stable Prosthesis so Fixation with curved locked plate with Uni-cortical screws Chosen for Treatment
Slide 95-

Example 12: Stable Prosthesis But Poor Bone Quality Plate Failure At 3 months
Slide 96-

Example 12: Stable Prosthesis But Poor Bone Quality Salvage with Proximal Femoral Replacement
Slide 97-

Conclusions Surgeon must carefully Evaluate Stability of the Implant Loose Fixation Implants will allow motion at the fracture site that interferes with healing and gets in the way of more stable fixation devices Loose Prosthetic Implants will be painful and also interfere with adequate fixation
Slide 98-

Conclusions If the prosthesis or implant is Loose, or Bone Quality is Poor - the implant should be revised while fixing the fracture
Slide 99-

Conclusions If the prosthesis or implant is Stable and Bone Quality is Adequate for Fixation the implant should be retained while the fracture is fixed following standard principles
Slide 100-

Review Articles Edward T. Su, Hargovind DeWal, and Paul E. Di CesarePeriprosthetic Femoral Fractures Above Total Knee ReplacementsJ. Am. Acad. Ortho. Surg., January/February 2004; 12: 12 – 20 Scott P. Steinmann and Emilie V. CheungTreatment of Periprosthetic Humerus Fractures Associated With Shoulder ArthroplastyJ. Am. Acad. Ortho. Surg., April 2008; 16: 199 - 207. Darin Davidson, Jeffrey Pike, Donald Garbuz, Clive P. Duncan, and Bassam A. MasriIntraoperative Periprosthetic Fractures During Total Hip Arthroplasty. Evaluation and Management J. Bone Joint Surg. Am., Sep 2008; 90: 2000 - 2012. Neil P. Sheth, David I. Pedowitz, and Jess H. LonnerPeriprosthetic Patellar Fractures J. Bone Joint Surg. Am., Oct 2007; 89: 2285 - 2296.
Slide 101-

Selected References Rad Zdero, Richard Walker, James P. Waddell, and Emil H. SchemitschBiomechanical Evaluation of Periprosthetic Femoral Fracture FixationJ. Bone Joint Surg. Am., May 2008; 90: 1068 - 1077. Timothy Bhattacharyya, Denis Chang, James B. Meigs, Daniel M. Estok, II, and Henrik MalchauMortality After Periprosthetic Fracture of the FemurJ. Bone Joint Surg. Am., Dec 2007; 89: 2658 - 2662. William M. Ricci, Brett R. Bolhofner, Timothy Loftus, Christopher Cox, Scott Mitchell, and Joseph Borrelli, Jr.Indirect Reduction and Plate Fixation, without Grafting, for Periprosthetic Femoral Shaft Fractures About a Stable Intramedullary Implant. Surgical TechniqueJ. Bone Joint Surg. Am., Sep 2006; 88: 275 - 282. Gregg R. Klein, Javad Parvizi, Venkat Rapuri, Christopher F. Wolf, William J. Hozack, Peter F. Sharkey, and James J. PurtillProximal Femoral Replacement for the Treatment of Periprosthetic FracturesJ. Bone Joint Surg. Am., Aug 2005; 87: 1777 - 1781. Zarin, JS, Zurakowski, D, and Burke, DW: J.Arthroplasty. 2009 Feb;24(2):272-80 Claw Plate Fixation of the Greater Trochanter in Revision Total Hip Arthroplasty
Slide 102-

Selected References Orthop Clin North Am. 1999 Apr;30(2):249-57The treatment of periprosthetic fractures of the femur using cortical onlay allograft struts.Brady OH, Garbuz DS, Masri BA, Duncan CP. Instr Course Lect. 1998;47:237-42.Periprosthetic fractures of the femur: principles of prevention and management. Garbuz DS, Masri BA, Duncan CP. Instr Course Lect. 1998;47:251-6. Periprosthetic hip and knee fractures: the scope of the problem.Younger AS, Dunwoody I, Duncan CP. Am J Orthop. 1998 Jan;27(1):35-41 One-stage revision of periprosthetic fractures around loose cemented total hip arthroplasty.Incavo SJ, Beard DM, Pupparo F, Ries M, Wiedel J. Instr Course Lect. 2001;50:379-89.Periprosthetic fractures following total knee arthroplasty. Dennis DA Orthop Clin North Am. 2002 Jan;33(1):143-52, ix.Periprosthetic fractures of the femur. Schmidt AH, Kyle RF J Arthroplasty. 2002 Jun;17(4 Suppl 1):11-3.Management of periprosthetic fractures: the hip.Berry DJ. Clinical Orthopaedics & Related Research. (420):80-95, March 2004.Periprosthetic Fractures Evaluation and Treatment. Masri, Bassam; Meek, R M. Dominic; Duncan, Clive P Return to Lower Extremity Index If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@ota.org