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With increasing incidence of total knee arthroplasty (TKA), a concurrent rise in periprosthetic fractures is also expected. Although many periprosthetic fractures about a TKA can be fixed through locked plating, retrograde intramedullary nailing, or both, some fracture patterns combined with poor bone stock and/or osteolysis can offer a loose femoral component requiring TKA revision. TKA revision in the setting of periprosthetic fracture can be challenging and, often, nearly impossible as fractures that extend proximally may not be amenable to standard revision components. Distal femoral replacement may offer a more efficient, facile approach to treating periprosthetic fractures about a loose TKA component. Here, the role of distal femoral replacement is reviewed, offering indications, salient technical points, and tips to avoid pitfalls while allowing for immediate, reliable weight bearing in this challenging patient population.

Prosthetic joint infection is a common cause of hip revision surgery, typically managed with a staged protocol and an antibiotic cement spacer. Patients being treated for prosthetic joint infection are at risk of fracture below the level of the spacer. Fracture in the setting of periprosthetic infection is a complex problem that requires the treating surgeon to use multiple techniques to achieve a successful outcome. The purpose of this case report is to highlight surgical strategies to successfully manage periprosthetic fractures complicated by infection.

Periprosthetic fractures (PPFs) present unique challenges to orthopaedic surgeons in terms of limited cortical fixation options, poor bone quality, cement mantles, and stress risers introduced from the prosthesis. Various fixation strategies have been used in PPFs including the use of intramedullary nails, locked plates, unicortical locking screws, cerclage wires and cables, double-plating techniques, and allograft struts. Here, we will review the biomechanics of various fixation strategies used in PPFs.

A critical component in the evaluation of a patient with a periprosthetic hip fracture is determination of stem stability. Failure to critically evaluate preoperative radiographs and subsequently intraoperative stem position may result in an incorrect treatment algorithm and early catastrophic failure of the implant construct. In 2018, this is becoming a larger issue as demand for revision total hip arthroplasty increases. Several factors contribute to the type of implant used in these fractures and depend on age, activity level, comorbidities, and available bone stock. The purpose of this article is to review the evaluation of periprosthetic hip fractures around a loose stem and provide tips and tricks for their management to allow for a successful, long-lasting outcome.

Treatment of periprosthetic fractures above total knee arthroplasty remains challenging because of assessment of implant stability and the short segment of often osteoporotic bone available for distal fixation. Fractures with significant medial comminution should undergo retrograde intramedullary nailing or dual-implant fixation, as isolated lateral locked plating is not indicated. There are a multitude of objective and subjective factors incorporated into the decision to proceed with retrograde nailing including assessment of the patient's functional status, fracture morphology, implant stability, and compatibility of the prosthesis with retrograde nailing. Here, we review the steps to success in using retrograde intramedullary nailing in the treatment of specific periprosthetic fractures about total knee arthroplasty.

Nail plate combination technique can be applied in the setting of periprosthetic and interprosthetic fractures to promote reliable healing with a biomechanically favorable construct. Here, technical aspects and discussion of the technique are reviewed through a case of an 87-year-old woman who suffered from an interprosthetic "floating" total knee arthroplasty (TKA); a supracondylar distal femur fracture in between a total hip arthroplasty and a TKA, with a proximal tibial metaphyseal fracture below the TKA tibial base plate.

As the incidence of total knee arthroplasty increases, a concurrent increase in periprosthetic fractures will also occur. This article focuses on the most common fracture types and current strategies adopted to overcome this challenging clinical problem. Our goal is to outline the role of locking plates in the management of knee periprosthetic fractures.

Periprosthetic fractures remain a challenging component of every trauma practice. Total joints have become common in very elderly patients, creating a variety of implanted stress risers that make subsequent fractures unique challenges to address. This creates the need to build a construct that will allow for early weight bearing while trying to reduce the potential for further fractures in the same bone. A minimally invasive submuscular approach with long periprosthetic locking plates can be used for a periprosthetic femoral fracture.

Objective: To evaluate the fit of distal femur locking plates. Secondarily, we sought to compare plate fit among patients with and without a total knee arthroplasty (TKA)., Design: Retrospective., Setting: University hospital., Intervention: Standard length precontoured distal femur locking plates from 4 manufacturers were digitally templated onto each patient's pre-TKA and post-TKA radiographs., Main Outcome Measurements: The maximum distance from the plate to the lateral femoral cortex (plate-bone distance) was measured in the metaphyseal region. Mean plate-bone distances were compared between manufacturers and between pre-TKA and post-TKA radiographs., Results: All implants tested were undercontoured in all patients. Plate-bone distances ranged from 6.6 ± 0.4 mm to 8.0 ± 0.4 mm (mean ± SE) pre-TKA and 8.2 ± 0.3 mm to 8.6 ± 0.3 mm after TKA, indicating worse fit after arthroplasty (P < 0.001). There were also intermanufacturer differences, with Synthes and Smith & Nephew implants demonstrating the lowest plate-bone distances in the pre-TKA and post-TKA groups, respectively. Proportionally, plate-bone increase was greater in the female cohort (16%) compared with the male cohort (8%)., Conclusions: There was plate-bone mismatch for the distal femur locking plates tested in this study, due to undercontouring of the implants. After patients underwent TKA, poor implant fit was exacerbated. Surgeons must be aware of the potential for deformity if the proximal segment is brought into contact with the implant. These finding may help optimize implant design for the treatment of periprosthetic distal femur fractures.

Periprosthetic fractures after shoulder arthroplasty occur in up to 2% of patients. In patients with stable components who fail or cannot undergo nonoperative management, stable fixation is required. We present a new technique to obtain proximal fixation around the humeral component using a 4.5-mm large fragment plate and a 3.5-mm attachment plate.

The incidence of periprosthetic fractures have been increasing, and in patients with osteopenic bone, high body mass index, or a combination both, they are difficult to treat and pose a high risk for malunion. Previous studies have compared the use of locking plates and intramedullary nails, and have found that each has its own strengthens and drawbacks, but neither is superior in terms of treating periprosthetic fractures. Here, we present the technique and series of patients treated with a combination of a retrograde intramedullary nail and flare-to-flare lateral locking plate without the use of allograft or autograft supplementation.

Objectives: The goals of this study are to evaluate mortality after Vancouver B periprosthetic fractures and determine predictors of mortality; compare mortality among patients with loose femoral stems treated with revision arthroplasty versus fixation alone; compare mortality among patients with radiographically "indeterminate" fractures treated with revision or fixation; and evaluate the rate of return to surgery for patients who underwent revision compared with fixation., Design: Retrospective study., Setting: Three academic level 1 trauma centers., Patients/participants: Two hundred three patients treated for Vancouver B periprosthetic fractures., Intervention: N/A., Main Outcome Measurements: The primary outcome measure was mortality. The secondary outcome measure was reoperation because of infection, failure of fixation, dislocation, or other mechanical failure., Results: Overall 1-year survival was 87% and 5-year survival was 54%. Among patients with loose femoral stems, there was no significant difference with regard to survival between patients treated with fracture fixation or revision arthroplasty (1-year survival 83% vs. 85%, 5-year survival 41% vs. 58%). Among patients whose radiographs were classified as indeterminate, there was no significant difference between patients treated with fracture fixation alone or revision arthroplasty. There was no significant difference between total reoperation rates between the two groups (11% vs. 16%)., Conclusion: This study suggests that there is no discernible survival benefit to treating patients with periprosthetic fractures with either revision arthroplasty or fixation alone. Therefore, from a mortality perspective, when faced with Vancouver B periprosthetic fractures, the orthopaedic surgeon should feel comfortable performing the type of intervention he/she is most proficient to perform., Level of Evidence: Prognostic level III. See Instructions for Authors for a complete description of levels of evidence.

Fractures of the tibial shaft in patients with ipsilateral total knee arthroplasty are rare but difficult to treat. Nonoperative treatment of these fractures with casting or bracing limits weight bearing for an extended period and can result in unacceptable malalignment. Operative fixation with plate and screws also limits early weight bearing and requires healing of soft tissue that is of poor quality. The authors present a method of internal fixation that uses a standard intramedullary tibial nail and suprapatellar instrumentation. This method can easily be performed, avoids the tibial baseplate, and does not require alteration of the instrumentation or intramedullary nail.

Successful treatment of periprosthetic femur fractures, like all fractures, requires careful attention to understand the fracture pattern nuances, identifying and executing a rational treatment approach, and providing an appropriate postoperative recovery protocol. Unlike most other fractures, modification of standard techniques is often required to obtain a stable fixation construct, and there is a greater role for revision arthroplasty in the treatment of periprosthetic fractures. Optimal indications for surgical repair versus revision arthroplasty and optimal postoperative weight-bearing protocols remain uncertain. Reported outcomes for patients with periprosthetic femoral shaft fractures are generally good and are relatively consistent. Results for periprosthetic distal femur fractures, however, are less good and more inconsistent. Both periprosthetic femoral shaft and distal femur fractures are associated with relatively high mortality rates, approaching that of patients with hip fractures. This review should provide insight into the current solutions and challenges for the treatment of patients with periprosthetic femur fractures.