What is Periprosthetic Hip Fracture Management?
Total hip replacement or hip arthroplasty is a surgical procedure in which the worn out or damaged parts of the hip joint are removed and replaced with artificial components called prostheses or implants.
A periprosthetic hip fracture is a break in the bone around the implants of a total hip replacement. These fractures usually occur at the tip of the femoral stem, often preceded by a region of increased cortical thickening or “stress riser.” The treatment approaches involved in the restoration of hip function after a periprosthetic hip fracture are referred to as periprosthetic hip fracture management.
Management of Periprosthetic Hip Fracture
Periprosthetic hip fracture is a serious complication that most often warrants surgery. The typical approaches involved in the management of periprosthetic hip fractures include:
- Open reduction and internal fixation (ORIF)
- Revision hip arthroplasty
- A combination of both
Stable periprosthetic fractures may be treated by immobilization with a cast or brace and minimal weight-bearing. Unstable periprosthetic fractures require surgical intervention. If the implant is firmly attached, an open reduction and internal fixation procedure is carried out by re-aligning the bone fragments and stabilizing them using screws and plates. Bone grafts may be used to strengthen the weakened bone. If the implant is loose, your surgeon suggests joint revision surgery, where the implant is removed and replaced by a new prosthesis. Bone grafts may be used to strengthen the weakened bone, and a longer stem is used to secure the prosthesis deeper into the bone.
Preparation for Periprosthetic Hip Fracture Management
Preoperative preparation for periprosthetic hip fracture surgery may involve the following steps:
- A review of your medical history and physical examination are performed by your doctor to check for any medical issues that need to be addressed prior to surgery.
- Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could compromise the safety of the procedure.
- You will be asked if you have allergies to medications, anesthesia, or latex.
- You should inform your doctor of any medications, vitamins, or supplements you are taking or any conditions you have such as heart or lung disease.
- You may be asked to avoid medications such as blood thinners, aspirin, or anti-inflammatories for a specific period prior to surgery.
- You should refrain from alcohol or tobacco at least a few days prior to the surgery and several days after as it can hinder the healing process.
- You should not consume any solids or liquids at least 8 hours prior to surgery.
- You need to arrange for someone to drive you home after surgery.
- Signed informed consent will be obtained from you after the pros and cons of the surgery have been explained in detail.
Procedure for Periprosthetic Hip Fracture Management
Periprosthetic hip fracture management is often challenging as it is difficult to fix a fracture around a total hip arthroplasty. Factors such as multiple bone fragments, poor bone quality, and, in some instances, the presence of bone cement, can increase the complexity of the case. Hence, it is not unusual for these cases to last more than three hours.
In general, the periprosthetic hip fracture surgery is performed using general anesthesia and may involve the following steps:
- After adequately sterilizing the surgical area, your surgeon makes a long incision over the hip joint.
- The supporting structures of the hip are gently moved aside to access the joint area.
- Your surgeon will then analyze the joint area and based on the severity and type of fracture sustained, your surgeon will perform either open reduction and internal fixation or revision hip arthroplasty or a combination of both.
- After the repair, the hip joint is carefully examined for bleeding or any other damage and addressed accordingly.
- Range of motion and repair are confirmed and all surrounding tissues and structures are restored to their normal anatomic positions.
- Finally, the incision is closed with sutures and sterile dressings are applied.
Postoperative Care and Recovery
In general, postoperative care instructions and recovery after periprosthetic hip fracture surgery may involve the following:
- You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anesthetic reactions and monitor your vital signs as you recover.
- Most patients will need to stay in the hospital for 2 to 3 days before discharge to home.
- You may notice pain, swelling, and discomfort in the hip area. Pain and anti-inflammatory medications are provided as needed for comfort.
- Intravenous antibiotics are also administered for 24 hours to prevent the risk of surgery-related infection.
- You will be placed on assistive devices such as crutches with instructions on restricted weight-bearing for a specified period of time. You are encouraged to walk with assistance as frequently as possible to prevent blood clots.
- Instructions on surgical site care and bathing will be provided to keep the wound clean and dry.
- Refrain from strenuous activities for the first few months and lifting heavy weights for at least 6 months. A gradual increase in activities over a period of time is recommended.
- An individualized physiotherapy protocol will be designed to help strengthen hip muscles and optimize hip function once you are off crutches.
- Most patients are able to resume their normal activities in 3 to 4 weeks after surgery; however, return to sports may take at least 6 months or longer.
- Refrain from driving until you are fully fit and receive your doctor’s consent.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Risks and Complications
Periprosthetic hip fracture surgery is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as the following:
- Damage to nerves and vessels
- Blood clots in the legs or lungs
- Anesthetic/allergic reactions
- Continued pain or stiffness
- Failure of the bone graft
- Failure of the fixation devices
- Implant failure
- The need for revision surgery