The Traumaplasty Continuum: Instructional Course Lecture Addresses Fractures in Patients with Hip and Knee Implants

Total hip and knee arthroplasties are common and increasing, with the projected volume hitting 1.9 million to 2.6 million by 2030. Of these patients, a substantial number will have a fall and require fracture repair. At the AAOS 2025 Annual Meeting, Instructional Course Lecture 452, “The Traumaplasty Continuum: Fixation and Revisions for Periprosthetic Fractures of the Hip and Knee,” provided tips and tricks for succeeding in these tricky cases.

Ellen Fitzpatrick, MD, FAAOS, a trauma surgeon and associate clinical professor at the University of California (UC) Davis Health, weighed in on strategies to repair periprosthetic fractures. She started with the Vancouver classification, a common system to grade periprosthetic fractures. The system takes into account a fracture’s location, as well as the implant’s stability and the quality of bone, providing an algorithm for treatment. Vancouver B describes issues around the femoral stem. B1 supposes a stable implant and calls for open reduction and internal fixation (ORIF). B2 describes an unstable implant and good bone, calling for revision or ORIF. B3 is an unstable implant and poor bone, requiring revision.

“As a trauma surgeon, this Vancouver B area is really where I live, and where my angst lives: trying to figure out which of these are stable or not stable,” Dr. Fitzgerald said. “I’m pretty far out of the arthroplasty game, so I’m trying to decide whether this is something I should be taking care of or something I should be discussing with colleagues.”

The key to deciding when to call in an arthroplasty specialist is implant stability, and radiographs can provide clues. Dr. Fitzgerald looks for implant subsidence, shifts in position, radiolucency of the cortex around the stem or in the bone/cement interface, and distal pedestaling or reactive sclerosis around the femoral component (suggesting a loose component prior to fracture). Determining implant stability requires the surgeon to carefully evaluate the injury films and, if possible, compare them to previous films. CT can also provide helpful insights. Still, determination of implant stability in these complex injuries can be challenging.

Dr. Fitzgerald described how revision surgery for Vancouver B2 has been the mainstay treatment for about 20 years. In the past 5 to 10 years, however, there has been more use of ORIF. Many surgeons report shorter surgical times, lower transfusion rates, and better experiences for geriatric patients with comorbidities with the use of ORIF.

She also covered a variety of fixation strategies, including cerclage, locking plates, and dual plating, as well as how to choose between long and short plates. In addition, cortical allograft struts can improve stability, particularly if bone is missing.

Revising periprosthetic hip fractures
Gillian Soles, MD, FAAOS, an associate professor of orthopaedic surgery at UC Davis Health and the session’s moderator, described several approaches to managing periprosthetic hip fractures. She assesses implant stability on preoperative imaging and intraoperatively reduces and provisionally stabilizes the proximal femur to permit revision stem reaming and insertion. She also places a cable, distal to the fracture, to prevent fracture propagation.

“If you’ve never had a femoral spiral fracture propagate, you haven’t done enough of these,” she said. “It’s going to happen to you.”

Later in her talk, Dr. Soles discussed a variety of techniques, including choosing between monoblock and modular stems. One meta-analysis showed no significant differences in these stems for hip function, re-revision rates, and complications. However, the risk of intraoperative fracture was higher in modular designs and the risk of subsidence was more common in monoblock.

Managing distal femur fractures
Michael Blankstein, MD, an assistant professor of orthopaedics and rehabilitation at the University of Vermont Medical Center, discussed distal femoral replacement (DFR), which is an option for cases with poor bone quality or low bone stock. “I truly believe that DFR should be the last resort,” he said, “but once in a while, we do believe that it’s the correct operation.”

Mark Lee, MD, chief of trauma service and orthopaedic trauma fellowship director at UC Davis Health, weighed in on periprosthetic distal femoral fractures, noting that the treatment landscape for this indication has shifted in recent years. “Most of what I was taught about distal femur are things I no longer believe because they’re based on old thinking, old implants,” Dr. Lee said. “I just don’t think they make sense to me anymore.”

He advised surgeons to nail every possible distal femoral fracture. He notes that many think they cannot nail extremely distal fractures, but he and others disagree. He said, “If you’re used to using a certain nail, open your eyes and look at all the other companies and all the offerings they have with really good technology for distal femur fractures.”

Josh Baxt is a freelance writer for AAOS Now.

References

1. Sloan M, Premkumar A, Sheth NP: Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am 2018;100(17):1455-60.
2. Uzoigwe CE, Watts AT, Briggs P, Symes T: Periprosthetic femoral fractures—beyond B2. J Am Acad Orthop Surg Glob Res Rev 2024;8(8):e23.00135.
3. Di Martino A, Brunello M, Villari E, et al: Stem revision vs. internal fixation in Vancouver B2/B3 periprosthetic hip fractures: systematic review and metanalysis. Arch Orthop Trauma Surg 2024;144(8):3787-96.
4. Wang D, Li H, Zhang W, et al: Efficacy and safety of modular versus monoblock stems in revision total hip arthroplasty: a systematic review and meta-analysis. J Orthop Traumatol 2023;24(1):50.
5. Nino S, Parry JA, Avilucea FR, et al: Retrograde intramedullary nailing of comminuted intra-articular distal femur fractures results in high union rate. Eur J Orthop Surg Traumatol. 2022;32(8):1577-82.