Periprothetische Frakturen: Grundlagen, Klassifikation und Therapieprinzipien

Periprosthetic fractures: basics, classification and treatment principles

Zusammenfassung

Periprothetische Frakturen (PPFx) besitzen aufgrund der steigenden Zahlen von Endoprothesenimplantationen an den großen Gelenken einen zunehmenden Stellenwert im orthopädisch-unfallchirurgischen Klinikalltag. Mit dem Unified Classification System (UCS) wurden zahlreiche historische Klassifikationssysteme ersetzt und in Anlehnung an die AO- und Vancouver-Klassifikation ein neues Klassifikationssystem etabliert. Die Therapie der PPFx ist individuell unter Berücksichtigung patientenabhängiger und patientenunabhängiger Faktoren zu treffen. Die konservative Behandlung der PPFx stellt eher die Ausnahme dar. Hingegen ist für die Wahl der operativen Behandlung und Entscheidung zwischen Osteosynthese oder Revisionsendoprothese besonders die Beurteilung der Stabilität des Implantates wichtig. Um eine Frakturkonsolidierung mit darüber hinaus gutem funktionellem Outcome zu erreichen, ist die Kenntnis über biomechanische Grundprinzipien der operativen (osteosynthetischen oder endoprothetischen) Versorgung periprothetischer Frakturen notwendig.

Abstract

Periprosthetic fractures (PPFx) are becoming an increasingly important topic in orthopedics and trauma surgery due to the rising number of endoprosthetic joint replacements. The recently published unified classification system (UCS) has replaced numerous historical classification systems and can be applied to all PPFx regardless of the bone or joint involved. The treatment of PPFx requires individual therapeutic concepts taking patient-dependent and patient-independent factors into consideration. The conservative treatment of PPFx is only justified in exceptional situations. In contrast, the choice between operative treatment and deciding between osteosynthesis or revision arthroplasty is particularly based on the assessment of the implant stability. In order to achieve fracture consolidation and also a good functional outcome, knowledge of the basic biomechanical principles of operative (osteosynthesis or endoprosthesis) treatment of periprosthetic fractures is necessary.

This is a preview of subscription content, log in to check access.

Abb. 1
Abb. 2
Abb. 3
Abb. 4

Literatur

  1. 1.

    Garcia P, Domnick C, Lodde G, Raschke MJ (2018) Operative Versorgung in Orthopädie und Unfallchirurgie. Unfallchirurg 121:20–29

    CAS  PubMed  Google Scholar 

  2. 2.

    Lindahl H, Garellick G, Regnér H, Herberts P, Malchau H (2006) Three hundred and twenty-one Periprosthetic femoral fractures. J Bone Joint Surg 88:1215–1222

    PubMed  Google Scholar 

  3. 3.

    Fath R (2018) Knie-Totalendoprothesen Ein anspruchsvoller Gelenkersatz. Dtsch Arztebl 115(8):A-332 https://www.aerzteblatt.de/int/article.asp?id=196421

    Google Scholar 

  4. 4.

    García-Fernández C, Lópiz-Morales Y, Rodríguez A, López-Durán L, Martínez FM (2015) Periprosthetic humeral fractures associated with reverse total shoulder arthroplasty: incidence and management. Int Orthop 39:1965–1969

    PubMed  Google Scholar 

  5. 5.

    Peterson CA, Lewallen DG (1996) Periprosthetic fracture of the acetabulum after total hip arthroplasty. J Bone Joint Surg 78:1206–1213

    CAS  PubMed  Google Scholar 

  6. 6.

    Rocca GJD, Leung KS, Pape H‑C (2011) Periprosthetic fractures: epidemiology and future projections. J Orthop Trauma 25(Suppl 2):S66–S70

    PubMed  Google Scholar 

  7. 7.

    Kenny P, Rice J, Quinlan W (1998) Interprosthetic fracture of the femoral shaft. J Arthroplasty 13:361–364

    CAS  PubMed  Google Scholar 

  8. 8.

    Agten CA, Sutter R, Pfirrmann CWA (2014) CT and MRI of hip arthroplasty. Radiologe (54):715–725 (quiz 726). https://doi.org/10.1007/s00117-014-2693-8

    Google Scholar 

  9. 9.

    Valle CJD, Momberger NG, Paprosky WG (2003) Periprosthetic fractures of the acetabulum associated with a total hip arthroplasty. Instr Course Lect 52:281–290

    PubMed  Google Scholar 

  10. 10.

    Davidson D, Pike J, Garbuz D, Duncan CP, Masri BA (2008) Intraoperative periprosthetic fractures during total hip arthroplasty. Evaluation and management. J Bone Joint Surg Am 90:2000–2012

    PubMed  Google Scholar 

  11. 11.

    Callaghan JJ, Kim YS, Pederson DR, Brown TD (1999) Periprosthetic fractures of the acetabulum. Orthop Clin North Am 30:221–234

    CAS  PubMed  Google Scholar 

  12. 12.

    Letournel E (1980) Acetabulum fractures: classification and management. Clin Orthop Relat Res 151:81–106

    Google Scholar 

  13. 13.

    Duncan CP, Masri BA (1995) Fractures of the femur after hip replacement. Instr Course Lect 44:293–304

    CAS  PubMed  Google Scholar 

  14. 14.

    Johansson JE, McBroom R, Barrington TW, Hunter GA (1981) Fracture of the ipsilateral femur in patients wih total hip replacement. J Bone Joint Surg Am 63:1435–1442

    CAS  PubMed  Google Scholar 

  15. 15.

    Whittaker RP, Sotos LN, Ralston EL (1974) Fractures of the femur about femoral endoprostheses. J Trauma 14:675–694

    CAS  PubMed  Google Scholar 

  16. 16.

    Mont MA, Maar DC (1994) Fractures of the ipsilateral femur after hip arthroplasty. A statistical analysis of outcome based on 487 patients. J Arthroplasty 9:511–519

    CAS  PubMed  Google Scholar 

  17. 17.

    Rorabeck CH, Taylor JW (1999) Classification of periprosthetic fractures complicating total knee arthroplasty. Orthop Clin North Am 30:209–214

    CAS  PubMed  Google Scholar 

  18. 18.

    Kim K‑I, Egol KA, Hozack WJ, Parvizi J (2006) Periprosthetic fractures after total knee arthroplasties. Clin Orthop Relat Res 446:167–175

    PubMed  Google Scholar 

  19. 19.

    Su ET, DeWal H, Cesare PED (2004) Periprosthetic femoral fractures above total knee replacements. J Am Acad Orthop Surg 12:12–20

    PubMed  Google Scholar 

  20. 20.

    Fakler JKM et al (2017) A new classification of TKA periprosthetic femur fractures considering the implant type. BMC Musculoskelet Disord 18:490

    PubMed  PubMed Central  Google Scholar 

  21. 21.

    Felix NA, Stuart MJ, Hanssen AD (1997) Periprosthetic fractures of the tibia associated with total knee arthroplasty. Clin Orthop Relat Res 345:113–124

    Google Scholar 

  22. 22.

    Goldberg VM et al (1988) Patellar fracture type and prognosis in condylar total knee arthroplasty. Clin Orthop Relat Res 236:115–122

    Google Scholar 

  23. 23.

    Ortiguera CJ, Berry DJ (2002) Patellar fracture after total knee arthroplasty. J Bone Joint Surg Am 84-A:532–540

    Google Scholar 

  24. 24.

    Pires RES et al (2014) Interprosthetic femoral fractures: proposed new classification system and treatment algorithm. Injury 45(Suppl 5):S2–S6

    Google Scholar 

  25. 25.

    Platzer P et al (2010) Management and outcome of interprosthetic femoral fractures. Injury 42:1219–1225

    PubMed  Google Scholar 

  26. 26.

    Wright TW, Cofield RH (1995) Humeral fractures after shoulder arthroplasty. J Bone Joint Surg Am 77:1340–1346

    CAS  PubMed  Google Scholar 

  27. 27.

    Worland RL, Kim DY, Arredondo J (1999) Periprosthetic humeral fractures: management and classification. J Shoulder Elbow Surg 8:590–594

    CAS  PubMed  Google Scholar 

  28. 28.

    Campbell JT, Moore RS, Iannotti JP, Norris TR, Williams GR (1998) Periprosthetic humeral fractures: mechanisms of fracture and treatment options. J Shoulder Elbow Surg 7:406–413

    CAS  PubMed  Google Scholar 

  29. 29.

    Duncan CP, Haddad FS (2014) The unified classification system (UCS): improving our understanding of periprosthetic fractures. Bone Joint J 96-B:713–716

    CAS  PubMed  Google Scholar 

  30. 30.

    Schütz M, Perka C (2013) Periprosthetic fracture management https://doi.org/10.1055/b-0034-91696

    Google Scholar 

  31. 31.

    Moran MC, Brick GW, Sledge CB, Dysart SH, Chien EP (1996) Supracondylar femoral fracture following total knee arthroplasty. Clin Orthop Relat Res 324:196–209

    Google Scholar 

  32. 32.

    Culp RW et al (1987) Supracondylar fracture of the femur following prosthetic knee arthroplasty. Clin Orthop Relat Res: 212–222

  33. 33.

    Stolberg-Stolberg J, Domnick C, Raschke M (2019) Periprothetische Frakturen am Knie. Knie J 1:123–136

    Google Scholar 

  34. 34.

    Siekmann H et al (2020) Konservative Therapie periprothetischer Humerusfrakturen Jahre nach zementierter Frakturprothese. Unfallchirurg 123:29–35

    CAS  PubMed  Google Scholar 

  35. 35.

    Fulkerson E (2006) Fixation of periprosthetic femoral shaft fractures associated with cemented femoral stems. J Orthop Trauma 20:89–93

    PubMed  Google Scholar 

  36. 36.

    Chatziagorou G, Lindahl H, Kärrholm J (2019) Lower reoperation rate with locking plates compared with conventional plates in Vancouver type C periprosthetic femoral fractures: a register study of 639 cases in Sweden. Injury 50:2292–2300

    PubMed  Google Scholar 

  37. 37.

    Gautier E, Sommer C (2003) Guidelines for the clinical application of the LCP. Injury 34:63–76

    Google Scholar 

  38. 38.

    Stoffel K, Dieter U, Stachowiak G, Gächter A, Kuster MS (2003) Biomechanical testing of the LCP—how can stability in locked internal fixators be controlled? Injury 34:11–19

    Google Scholar 

  39. 39.

    Lenz M, Lehmann W, Wähnert D (2016) Periprosthetic fracture fixation in osteoporotic bone. Injury 47(Suppl 2):S44–S50

    PubMed  Google Scholar 

  40. 40.

    Lenz M et al (2012) Biomechanical performance of different cable and wire cerclage configurations. Int Orthop 37:125–130

    PubMed  PubMed Central  Google Scholar 

  41. 41.

    Wähnert D, Lenz M, Schlegel U, Perren S, Windolf M (2011) Cerclage handling for improved fracture treatment. A biomechanical study on the twisting procedure. Acta Chir Orthop Traumatol Cech 78:208–214

    PubMed  Google Scholar 

  42. 42.

    Gwinner C et al (2015) Bicortical screw fixation provides superior biomechanical stability but devastating failure modes in periprosthetic femur fracture care using locking plates. Int Orthop 39:1749–1755

    PubMed  Google Scholar 

  43. 43.

    Hoffmann MF et al (2014) Biomechanical evaluation of fracture fixation constructs using a variable-angle locked periprosthetic femur plate system. Injury 45:1035–1041

    PubMed  Google Scholar 

  44. 44.

    Lenz M et al (2012) The locking attachment plate for proximal fixation of periprosthetic femur fractures—a biomechanical comparison of two techniques. Int Orthop 36:1915–1921

    PubMed  PubMed Central  Google Scholar 

  45. 45.

    Giesinger K et al (2013) Can plate osteosynthesis of periprosthethic femoral fractures cause cement mantle failure around a stable hip stem? A biomechanical analysis. J Arthroplasty 29:1308–1312

    PubMed  Google Scholar 

  46. 46.

    Kampshoff J, Stoffel KK, Yates PJ, Erhardt JB, Kuster MS (2009) The treatment of periprosthetic fractures with locking plates: effect of drill and screw type on cement mantles: a biomechanical analysis. Arch Orthop Trauma Surg 130:627–632

    PubMed  Google Scholar 

  47. 47.

    Wähnert D et al (2017) Double plating in Vancouver type B1 periprosthetic proximal femur fractures: A biomechanical study. J Orthop Res 35:234–239

    PubMed  Google Scholar 

  48. 48.

    Lenz M et al (2016) Enhancing fixation strength in periprosthetic femur fractures by orthogonal plating—A biomechanical study. J Orthop Res 34:591–596

    PubMed  Google Scholar 

  49. 49.

    Lee J‑M, Kim T, Kim T (2018) Treatment of periprosthetic femoral fractures following hip arthroplasty. Hip Pelvis 30:78–85

    PubMed  PubMed Central  Google Scholar 

  50. 50.

    Müller FJ, Galler M, Füchtmeier B (2014) Clinical and radiological results of patients treated with orthogonal double plating for periprosthetic femoral fractures. Int Orthop 38:2469–2472

    Google Scholar 

  51. 51.

    Medda S, Snoap T, Carroll EA (2019) Setting yourself up for success. J Orthop Trauma 33:S29–S32

    PubMed  Google Scholar 

  52. 52.

    Lehmann W et al (2012) What is the risk of stress risers for interprosthetic fractures of the femur? A biomechanical analysis. Int Orthop 36:2441–2446

    PubMed  PubMed Central  Google Scholar 

  53. 53.

    Weiser L et al (2014) The role of inter-prosthetic distance, cortical thickness and bone mineral density in the development of inter-prosthetic fractures of the femur. Bone Joint J 96-B:1378–1384

    CAS  PubMed  Google Scholar 

  54. 54.

    Soenen M, Baracchi M, Corte RD, Labey L, Innocenti B (2013) Stemmed TKA in a femur with a total hip arthroplasty: is there a safe distance between the stem tips? J Arthroplasty 28:1437–1445

    PubMed  Google Scholar 

  55. 55.

    Shin Y‑S, Kim H‑J, Lee D‑H (2016) Similar outcomes of locking compression plating and retrograde intramedullary nailing for periprosthetic supracondylar femoral fractures following total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 25:2921–2928

    PubMed  Google Scholar 

  56. 56.

    Cohen S, Flecher X, Parratte S, Ollivier M, Argenson JN (2018) Influence of treatment modality on morbidity and mortality in periprosthetic femoral fracture. A comparative study of 71 fractures treated by internal fixation or femoral implant revision. Orthop Traumatol Surg Res 104:363–367

    CAS  PubMed  Google Scholar 

  57. 57.

    Langenhan R et al (2012) Weight bearing reduced mortality

    Google Scholar 

  58. 58.

    Perrin A et al (2018) The benefit of the systematic revision of the acetabular implant in favor of a dual mobility articulation during the treatment of periprosthetic fractures of the femur: a 49 cases prospective comparative study. Eur J Orthop Surg Traumatol 28:239–246

    CAS  PubMed  Google Scholar 

  59. 59.

    Bozic KJ, Freiberg AA, Harris WH (2004) The high hip center. Clin Orthop Relat Res 420:101–105

    Google Scholar 

  60. 60.

    Wirtz C, Niethard FU (1997) Ursachen, Diagnostik und Therapie der aseptischen Hüftendoprothesenlockerung – eine Standortbestimmung. Z Orthop Unfall 135(4):270–280. https://doi.org/10.1055/s-2008-1039388

  61. 61.

    Dohmae Y, Bechtold JE, Sherman RE, Puno RM, Gustilo RB (1988) Reduction in cement-bone interface shear strength between primary and revision arthroplasty. Clin Orthop Relat Res 236:214–220

    Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Dr. J. Everding.

Ethics declarations

Interessenkonflikt

J. Everding, B. Schliemann und M.J. Raschke geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

Additional information

Redaktion

Prof. Raschke

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Everding, J., Schliemann, B. & Raschke, M.J. Periprothetische Frakturen: Grundlagen, Klassifikation und Therapieprinzipien. Chirurg (2020). https://doi.org/10.1007/s00104-020-01219-2

Download citation

Schlüsselwörter

  • Unified Classification System
  • Risikofaktoren
  • Konservative Therapie
  • Osteosynthese
  • Revisionsendoprothetik

Keywords

  • Unified classification system
  • Risk factors
  • Conservative treatment
  • Osteosynthesis
  • Revision arthroplasty