Periprosthetic fractures relatively common

and are challenging! Incidence: Primary THR (Cemented Stems) Primary THR (Uncemented Stems) Revision THR (Cemented stems) Revision THR (Uncemented stems) Hemiarthroplasty (Cemented) Hemiarthroplasty (Uncemented)

<1% 5% 4% 21% 2% 11%

Elderly patients Poor bone quality Co-morbidities Lengthy procedures Increased length of stay Prolonged rehabilitation Surgical expertise Expensive!

By Duncan and Masri in 1995 High Inter and Intra observer reliability Proposes an accurate and effective treatment protocol

Can occur intr-operatively Associated with osteopenia / osteolysis Mostly non-operative management; unless extend into calcar / affect stability Managed by cables / Trochanteric plates

Fracture distal to intertrochanetric region, but around the stem By definition- A well fixed stem! Morphology of fracture dictates treatment options Cable / Circlage wiring +/ plating (uni/ biplanar) +/ cortical strut onlay allograft (for local osteolysis)

Fractures around stem leading to loosening and involving cement mantle Loosening of stem determined on x-rays / introperatively Subsidence, shift in stem position, lucency in bone cement interface (Gruen zones), osteolysis and reactive sclerosis around stem. Best treated by Uncemented modular long Revision stems-bypassing the fracture site by 2 femoral cortical diameters (at least 7cm). Role of cemented stem revisions-very minimal

Fractures associated with osteopenia or deficient bone Treatment dependent on patients age and activity level Allograft prosthetic composite reconstruction Proximal femoral replacement

Fractures distal to stem Tip Treated by ORIF- Plating +/ cables / wires Retrograde nailing for very distal fractures ?

Differentiation of B1 /B2 is most challenging and detrimental in management and outcome 1 year mortality rate for Type B fractures: Treated by Revision arthroplasty 12% Treated by ORIF 33% Increase in 1 year mortality rate if surgery delayed for > 2 days from admission!

Retrospective study 146 patients treated between 1999-2009 62% Female, Mean age 79 years Fractures around THR-63, Revision-27, Hemi-57 Non operative- 23 cases ORIF-61 Cases Revision-62 cases

Cost of ward per day460 Elderly ward ICU and HDU Cost of theatre time / per hour 480 All investigations cost Not included-Long term residential / institutional care

Avg length of stay 38 days

Total cost of treatment for all patients-3,426,483 Avg cost per pt-23,469 ,(20,172)

No statistical difference between treatment modality No statistical difference between THR / Hemi # No statistical difference between </>2 medical comorbidities Significant difference in cost between one procedure and > 1 procedure (p=0.01) Length of stay >30 days had significant impact on costing (p<0.0001) Average loss per patient as per PBR- 12, 561! (Money received 1000-8000)

Avg Hospital cost 23,469 Main components of cost Length of stay 80% Op-time 6% Implants cost 7% Investigations 7% Complications of treatment has high impact on further costs

Study highlights the financial implications of these increasingly common fractures Large series from tertiary centre If <30 days stay-Cost Neutral! Fails to explain reasons for >30 days stay despite no major complications in some cases Implant costings only 7%? Accuracy of cost analysis is questionable?