Long-term survival of total hip replacement after periprosthetic fracture treated with internal fixation and complicated with deep prosthetic infection

G. Skouteris, A. Giannakopoulos, I. Nikolopoulos, M. Dagiakidis, C. Tzioupis
2nd Orthopaedic Department, “Asclepeion Voulas” Hospital

ABSTRACT
We present a case of long-term survival of a cementless total hip replacement (THR) in a female patient who - a year later - sustained a periprosthetic fracture of femur, following a high energy injury. The femoral prosthesis was stable and the periprosthetic fracture was treated with internal fixation. Eight months later, the patient developed deep prosthetic infection complicated with sinus and discharge. The deep infection was treated with extensive surgical debridement after removal of plate and screws, local antibiotic beads and long-term culture-based intravenous antibiotics.
The infection was successfully treated and the THR was preserved and survived having good functional result, as was confirmed in recent clinical and radiological follow up, 11 years after the primary operation.
The prognosis of post operative periprosthetic fractures depends not only on the site of the fracture, the prosthesis stability and the bone stock, but also on the high complication rate of their treatment. The high complication rate of pseudarthrosis, malunion and, especially, infection, lead to THR failure.
In our case, the additional severe complication of deep prosthetic infection after the periprosthetic fracture treatment did not lead to destabilization and failure of THR, because of the thorough surgical debridment after plate and screws removal and the proper antibiotic therapy.
In similar cases of femoral periprosthetic fracture in cementless THR with stable femoral stem, we consider that the fracture osteosynthesis is rather preferable than the THR revision as it gives better results even after prosthetic infection, as is demonstrated in our case.

Key words: Periprosthetic fracture, prosthetic infection, total hip replacement.

Figure 1a: 60 year-old female patient with (L) hip (OA), treated with cementless total hip replacement.


Figure 1b: Periprosthetic femoral fracture B1 Vancouver type, without signs of prosthesis loosening or bone absorption, which was fixed with plate and screws.


Figure 1c: Six months after the internal fixation, the fracture had been united and the arthroplasty had good functional result.

CASE REPORT
A sixty (60) year-old female patient with (L) hip osteoarthritis (OA) was treated with cementless Total Hip Replacement (THR) (figure 1a) and a year after the primary operation sustained a periprosthetic femoral fracture.
The injury was a high energy one, following a fall from a height, and the initial radiological imaging revealed a B1 Vancouver periprosthetic fracture, with no signs of loosening or bone absorption. During the operation, the stability of femoral prosthesis was verified and the fracture was stabilized with plate and screws. The post operative period was uneventful and the patient was discharged under follow up, able to walk with crutches and progressive weight bearing (figure 1b).
At the 6 months follow up, the periprosthetic fracture was united and the THR had a good functional result (figure 1c).
Eight months after the periprosthetic fracture osteosynthesis, the patient developed deep prosthetic infection complicated with sinus and discharge. Sinography took place, following the swab sampling for potential germ growth (figure 2a).
The immediate treatment included extensive surgical debridement, removal of plate and screws and local antibiotic beads. Post operatively, a culture-based antibiotic course was administered to the patient for a 6 weeks period. The post operative period was uneventful and the patient was discharged, continuing oral antibiotics for one more month, and returned to previous activities, two months after the operation. Thereafter, the patient was under annual clinical and radiological follow up (figure 2b).
During recent follow up, 11 years after the THR and 10 years after the periprosthetic fracture osteosynthesis, the clinical result was good, the HHS was 90 and there were no radiological signs of infection or loosening (figure 3).

Figure 2a: Eight months after the periprosthetic fracture osteosynthesis, the patient developed deep prosthetic infection, complicated with sinus and discharge. Sinography after swab sampling.


Figure 2b: Removal of plate and screws, surgical debridment and local antibiotic beads.
One year follow-up.


Figure 3: At a recent follow up, the result is satisfactory with HHS of 90 and with no infection or loosening signs.

DISCUSSION
The rate of post operative periprosthetic fractures increases with the rise of the number of patients with THR, the rise of the patients with femoral prosthesis loosening and the rise of THR revisions[1,4,12,14].
In relatively young patients, with good bone quality and high daily activity, a periprosthetic fracture usually occurs after high energy injury, whereas in elderly patients, with poor bone quality, such fractures occur after a low energy injury.
Several periprosthetic femoral fractures classification in THR have been reported until now, considering the site, the prognosis or the type and the severity of the fracture[2,6,7,8]. We regard the Vancouver[5] one as the best and most comprehensive classification. The Vancouver classification considers the fracture site, the prosthesis stability and the bone quality, and recommends, in respect of those parameters, the most suitable treatment for each fracture type.
The periprosthetic femoral fractures still consist a major issue regarding the surgical treatment, given the fact of high complication rate, such as pseudarthrosis, malunion and infection, that may affect the prosthetic functionality and lead to loosening or failure of the total arthroplasty[9,10,13]. The fracture type, the kind of arthroplasty and the complications differentiate the rate of successful treatment and survival of the THR after periprosthetic fracture[3,12].
In our case, the periprosthetic fracture of the femur was B1 Vancouver and it has been treated with the appropriate plate and screws osteosynthesis as recommended. Despite the initial uneventful post operative period and the subsequent fracture union, the new complication of deep prosthetic infection was successfully treated, providing finally long-term survival of the total hip arthroplasty.
Reviewing the recent literature, one case has been reported, so far, including combination of periprosthetic femoral fracture and deep prosthetic infection that was treated in two stages, by removal of the prosthesis, temporary stabilization, intravenous antibiotics and, at a later point, THR revision[11].
There has not yet been reported any case of long term survival of THR after periprosthetic femoral fracture, in which, after the osteosynthesis and the fracture union, a new complication with deep prosthetic infection developed, which was successfully treated with extensive surgical debridement and intravenous antibiotics.
We consider that the final successful result and the long term, over 11 years, survival of the total arthroplasty is the result of the osteosynthesis of the femoral fracture with stable prosthesis and good bone stock, as well as the result of the extensive surgical debridement and intravenous antibiotics administration for the deep infection.
Conclusively, it is a fact that the post operative femoral periprosthetic fractures after a total hip arthroplasty are a major problem and their treatment and results depend on the fracture type, the femoral prosthesis stability and the bone stock around the prosthesis.
The osteosynthesis of B1 Vancouver type fractures with stable prosthesis preserves a significant percentage among THR’s, so that the revision of THR, with or without cement, ought to be chosen as treatment of a non-stable prosthesis.
In our case, the periprosthetic fracture osteosynthesis lead to bone union. The new complication of deep infection was successfully treated with extensive surgical debridement and long-term culture-based antibiotics. The THR, after the successful treatment of the sequel of complications, finally survived having good functional result, as it was verified in the follow up, 11 years later.

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Mailing address:
G. Skouteris
Ippokratous 3, VoulaTel.: 210 8953166Email: giannako@otenet.gr