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Background: Due to the increase in hip and knee prosthetic as a result of the demographic changes, with raised levels of activity among older persons with geriatric comorbidities, a continuous increase in periprosthetic fractures can be observed., Objective: The incidence and causes of periprosthetic fractures, presentation of diagnostic pathways and derivation of a recommendation according to generally accepted classifications., Material and Method: Literature search of basic scientific work, recommendations of experts as well as evaluation of own patient collective., Conclusion: With a growing number of prosthetic interventions in combination with increasing patient age, an increase in periprosthetic fractures is to be expected. The treatment of periprosthetic fractures is complex and requires detailed analysis of the location of the fracture and its morphology as well as the recognition of possibly loosened prosthetic material. Based on this information, the correct surgical treatment can be determined and scheduled in an appropriate center of care. In geriatric patients with corresponding comorbidities, an individual holistic treatment plan should be developed., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Objective: The advantages of the direct anterior approach (DAA) in primary total hip arthroplasty as a minimally invasive, muscle-sparing, internervous approach are reported by many authors. Therefore, the DAA has become increasingly popular for primary total hip arthroplasty (THA) in recent years, and the number of surgeons using the DAA is steadily increasing. Thus, the question arises whether femoral revisions are possible through the same interval., Indications: Aseptic, septic femoral implant loosening, malalignment, periprosthetic joint infection or periprosthetic femoral fracture., Contraindications: A draining sinus from another approach., Surgical Technique: The incision for the primary DAA can be extended distally and proximally. If necessary, two releases can be performed to allow better exposure of the proximal femur. The DAA interval can be extended to the level of the anterior superior iliac spine (ASIS) in order to perform a tensor release. If needed, a release of the external rotators can be performed in addition. If a component cannot be explanted endofemorally, and a Wagner transfemoral osteotomy or an extended trochanteric osteotomy has to be performed, the skin incision needs to be extended distally to maintain access to the femoral diaphysis., Postoperative Management: Depending on the indication for the femoral revision, ranging from partial weight bearing in cases of periprosthetic fractures to full weight bearing in cases of aseptic loosening., Results: In all, 50 femoral revisions with a mean age of 65.7 years and a mean follow-up of 2.1 years were investigated. The femoral revision was endofemoral in 41 cases, while a transfemoral approach with a lazy‑S extension was performed in 9 patients. The overall complication rate was 12% (6 complications); 3 patients or 6% of the included patients required reoperations. None of the implanted stems showed a varus or valgus position. There were no cases of mechanical loosening, stem fracture or subsidence. Median WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score before surgery improved significantly from preoperative (52.5) to postoperative (27.2)., (© 2022. The Author(s).)

Objective: Stabilization of the humerus with preservation or restoration of the shoulder function., Indications: Always in the presence of a loose prosthesis. It may become necessary in conditions of poor bone stock and if osteosynthesis is not possible., Contraindications: Noncompliant patients due to alcohol or drugs. Local infections., Surgical Technique: The loose implant is removed using an extended anterior deltopectoral approach. After exploration of the fracture and extended soft tissue release, the glenoidal components are implanted with visualization and protection of the axillary nerve. A long stemmed implant is typically needed on the humeral side. It is anchored in the distal fragment over a length of about 6 cm. Soft tissue tension is crucial, especially with reverse shoulder arthroplasty., Postoperative Management: Postoperatively, the affected limb is immobilized for 6 weeks on a 15° shoulder abduction pillow with active assisted movement therapy up to the horizontal plane. This is followed by gradual pain-adapted increases of movement, muscle coordination, and strength., Results: In 17 patients with periprosthetic fractures of the humerus surgically treated in our institution, 4 underwent revision arthroplasty because of a loose prosthesis. No intra- or postoperative complications were observed. All fractures healed except one.

Objective: Intramedullary stabilization of periprosthetic distal femoral fractures by interlocking nailing. Closed reduction by retrograde nail can be combined with the use of transmedullary support screws (TMS principle of Stedtfeld)., Indications: Supracondylar fractures above stable knee arthroplasty (Rorabeck types I and II), femoral shaft fractures ipsilateral of stable hip and/or knee arthroplasty, contraindications for antegrade nailing, Contraindications: Closed box design of femoral implant, intercondylar distance of the femoral component smaller than nail diameter, more than 40° flexion deficit of the knee, inability to place two bicortical distal interlocking screws. Relative contraindication: insufficient overlap with proximal implants, Surgical Technique: Supine position and knee flexion of approximately 45°. Fluoroscopy should be possible between the knee and hip. Longitudinal skin incision into the pre-existing scar over the patellar tendon which is then split. The nail entry point is located in the intercondylar groove at the deepest point of Blumensaat's line, often predetermined by the femoral arthroplasty component. Reaming is rarely necessary. Transmedullary support screws may correct axial malalignment during nail insertion. Static interlocking in a direction from lateral to medial by the aiming device. Insertion of locking cap., Postoperative Management: Retrograde nailing normally allows full weight bearing. Range of motion does not need to be restricted., Results: Out of 101 fractures treated between 2000 and 2013 with a Targon RF nail (Aesculap, Tuttlingen, Germany) 10 were periprosthetic, all were classified as Rorabeck type II and of these 6 fractures were metaphyseal and 4 were diaphyseal. In four cases proximal implants were present. The mean operative time for periprosthetic fracture fixation did not significantly differ from that for normal retrograde femoral nailing. There were no postoperative infections, fixation failures or delayed unions. There was one revision for secondary correction of maltorsion.

Objective: Hip revision arthroplasty of a loose stem in the case of Vancouver type B2 and B3 periprosthetic fractures and cerclage wiring of the femoral shaft., Indications: Vancouver type B2 and B3 periprosthetic fractures of the proximal femur., Contraindications: Periprosthetic joint infection. Interprosthetic femoral fractures between the ends of hip and knee prosthetic stems that require total replacement of the femur., Surgical Technique: Extended posterolateral approach to the tip of the fracture. Exposure along the septum intermusculare laterale with ligation of the perforating vessels below the fracture. Longitudinal osteotomy of the proximal fragment above the linea aspera using an oscillating saw under cooling. Ventral proximal osteotomy at the corner of the vasto-gluteal sling after short muscular incision using an osteotome chisel. Opening of the proximal fragment with lifting up of the bony flap like a transfemoral approach. Removal of the loosened prosthetic stem and possibly the cement. Preparation of the distal fixation zone of the modular cementless revision stem in the isthmus of the femur distal of the fracture. Implantation of the distal component of the modular cementless revision stem. Use of additional distal interlocking screws in cases of destroyed isthmus with a fixation zone of less than 3 cm for the distal prosthetic component. Trial reposition after combination with the proximal trial component in situ. Assembly with the original proximal component in situ. Reposition with the original proximal component. Wound closure., Postoperative Management: Thrombosis prophylaxis, physiotherapy, gait training with partial loading of the limb at 10 kg for a period of 6 weeks with hip flexion limited to 70°. Then, free range of movement and increased loading by 10 kg per week., Results: In all, 23 patients with periprosthetic fractures of Vancouver type B2 (15 patients) and type B3 (eight patients)-in 15 women and eight men in the age range of 70.7 ± 12.2 (42-88) years-were followed up for at least 5 years. All fractures healed with a mean time of 14.4 ± 5.3 weeks. No cases of subsidence of the stem were observed and, according to the classification of Engh et al. concerning the biological fixation of the stem, there was bony ingrowth fixation in 21 cases and two cases of stable fibrous fixation. One dislocation occurred and there were no cases of intraoperative fracture. The Harris Hip Score rose continually following the operations: from a 3-month postoperative score of 65.0 ± 16.8 points, it rose to 86.9 ± 16.2 points after 24 months and to 89.0 ± 14.3 points after 5 years. According to the classification of Beals and Tower, all results were rated as excellent, i.e., the prefracture functional status was restored in all cases.