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- Unified Classification—ABCDEF
- A = Apophysis
- B = Bed of implant
- B1 = stable, B2 = unstable, B3 = poor bone stock
- C = Clear of implant
- D = Dividing 2 implants
- E = Each of 2 bones (e.g., femur and tibia)
- F = Facing implant (e.g., acetabulum with hemi)
- Similar to Vancouver Classification
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- Still need to rule out infection!
- CT scan to evaluate fracture
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- E.g., GT fracture
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- Mostly extramedullary implants
- If possible, bridge with plate
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- Uncemented long stem prosthesis bypassing defect by 2 cortical diameters
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- Options: cortical strut allograft, impaction bone grafting (with cemented long stem), allograft-prosthesis composite, proximal femoral replacement
- C = ORIF
- D = ORIF
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- In general, I will revise an unstable B2 fracture. However, there is new controversy suggesting fixation may be considered if the cement mantle is stable and anatomical reduction can be achieved.
- Investigate with CT scan
- Complex revision surgery
- Preop: anesthesia review, prepare explant sets, uncemented long stems, cement removal (OSCAR)
- Intraop EEERRRR
- Exposure—ensure adequate exposure, posterior extensile approach
- Clamp fragments down first (if you don't do this and attempt dislocation, the fracture will spiral and break apart further)
- Dislocate the hip → then remove the implant with clamps in place
- Explant
- Stem—remove cement as much as possible with osteotome proximally, then use OSCAR to remove distal cement and bone plug
- Cup—evaluate cup condition (attempt to retain the acetabular component, provided it is not loose or obviously worn, damaged, or malpositioned)
- Fix the fracture
- Fix fracture with periprosthetic fracture plates and cerclage wires
- Consider placing a reamer in the canal to act as a template for fixing the bone around it
- Replace
- Sequentially ream femur until chatter
- Replace with long stem uncemented, modular stem; bypass 2 cortical diameters (approximately 6 cm—when we drill it is 34, 36 mm...)
- Cemented after osteotomy or presence of fracture may compromise osteotomy healing
- Post-op: Rehabilitation—may begin with TTWB × 2/52 → PWB
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- Allows polyaxial, monocortical locking screws that can bypass the implant in the medullary canal
- Also has options for attachment to the GT for proximal fixation
- Options for cables to attach to the plate
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- Yes, this is an area of controversy.
- In general, I will revise an unstable B2 fracture. However, there is new controversy suggesting fixation may be considered if the cement mantle is stable and anatomical reduction can be achieved.
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- Reoperation rates are high when B3 fractures are treated with ORIF rather than revision: 30% reoperation rates vs. 15%.
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Open your mouth, judge righteously, defend the rights of the poor and needy. Proverbs 31:9