Patient preoperative evaluation
1. Introduction
Periprosthetic fractures are often demanding and require careful planning and preparation for successful treatment. Information is needed about the original arthroplasty procedure and implant as well as the usual information about the patient and the fracture.
2. Patient evaluation
Patients with periprosthetic fractures often present additional challenges, including:
- Frailty
- Dementia
- Osteoporosis
- Sarcopenia
- Comorbidities
- Prior or current periprosthetic infection
Diagnostic workup needs to include an assessment of these factors. However, elderly patients benefit from early mobilization and harm can be attributed to delays to surgery. Therefore, diagnostic workup needs to be performed promptly to enable surgery within a day or 2 of injury.
3. Prosthesis evaluation
Ideally, the details of the original arthroplasty operation should be available. It is useful to know the manufacturer and model of the prosthesis, the date of insertion, details of any perioperative complications, and information regarding prosthesis function.
4. Fracture evaluation
To evaluate and classify a periprosthetic fracture, the surgeon needs to assess not only the fracture location and configuration but also the presence of prosthetic loosening and the quality of bone stock. The Unified Classification System for Periprosthetic Fractures (UCPF) is a useful model to help this evaluation.
Diagnostic imaging is essential but needs to be interpreted in the context of clinical history and examination to enable a full evaluation of the prosthesis as well as the fracture. For example, regardless of imaging findings, indicators of possible periprosthetic loosening include:
- Preceding pain
- Deteriorating function
- Fracture with no history of trauma
- Previous or current infection
It is essential to exclude prosthetic joint infection and septic loosening. Clues to the presence of infection can be obtained on history:
- Previous treatment for infection
- Postoperative wound problems (e.g. prolonged serous ooze)
- Preceding pain
If an infection is suspected, diagnostic workup should include serologic workup, aspiration of the joint for cell count, microbiology and alpha-defensin, deep tissue samples from the prosthesis interface taken at surgery. Sometimes this needs to be done as a separate procedure before surgery for the periprosthetic fracture, especially if revision arthroplasty is planned.
5. Diagnostic imaging
It is essential to establish if a prosthetic component is well fixed or loose, as this would dictate whether internal fixation or revision surgery is the optimum treatment. Plain x-rays are useful, especially if previous images are available to allow comparison over time.
X-rays signs include:
- Lucency
- Subsidence
- Alignment change and osteolysis
CT scans can show more details of osteolysis and occult fractures.
Advanced MRI techniques can give more detail of the bone-implant interface.
6. Evaluation of patient needs
Elderly patients do not tolerate immobility and are usually unable to comply with protected weight-bearing instructions. It is important to establish if the patient requires early full weight-bearing and plan treatment to enable this.
Early full weight-bearing is the standard of treatment for elderly patients.
