Periprosthetic fractureMANAGEMENT

MUSCULOSKELETAL AND RHEUMATOLOGIC PRESENTATIONS · 12 SECTIONS

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659 items

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01Approach to the Critical Patient/attcp51

Immediate priorities

›Most periprosthetic fractures are low-energy fragility injuries in frail older adults, but a minority present unstable

›Occult thigh or retroperitoneal hemorrhage, especially on antiplatelet or anticoagulant therapy

›Fat embolism syndrome from femoral marrow, typically 12 to 72 hours after injury

›Associated injuries from the same fall: intracranial hemorrhage, cervical spine injury, rib fractures

›Undiagnosed periprosthetic joint infection presenting as a pathologic fracture with sepsis

›Structured primary survey in every elderly faller before focusing on the limb

›Airway and cervical spine precautions if the mechanism or exam suggests a head or neck injury

›Breathing: new hypoxemia raises fat embolism, aspiration, pulmonary edema, or pulmonary embolism

›Circulation: serial blood pressure and heart rate, wide-bore intravenous access, type and screen

›Disability: baseline cognition from a collateral source to allow later delirium detection

›Exposure: full skin survey for open wounds, pressure areas, and contralateral injury

›Early analgesia is a resuscitation priority, not a comfort measure

›Uncontrolled pain drives tachycardia, delirium, and pulmonary splinting in this population

›Prefer a regional block over escalating systemic opioids where a trained operator is available

›Identify the questions that drive definitive care while still in the emergency department

›Which bone and which implant, and whether the fracture is around a hip or a knee prosthesis

›Is the implant loose, because loosening converts fixation into revision arthroplasty

›Is the bone pathologic or infected, because that changes both the operation and the antibiotics

Hemorrhage and anticoagulation reversal

›Quantify blood loss early

›A closed periprosthetic femoral fracture can sequester 1 to 1.5 litres into the thigh

›Comminuted, interprosthetic, and fractures well below the stem bleed more

›Heart rate may be blunted by beta blockade, so a normal rate does not exclude hemorrhage

›Serial hemoglobin, not a single value, tracks ongoing loss

›Resuscitate with blood, not large-volume crystalloid, when bleeding is significant

›Transfuse red cells to a hemoglobin threshold of 70 g/l in the hemodynamically stable patient

›Use a threshold of 80 g/l with acute coronary syndrome, active myocardial ischemia, or symptomatic anemia

›Tranexamic acid 1 g IV over 10 minutes if there is significant bleeding and no contraindication

›Avoid with arterial or venous thrombosis within the prior 3 months or a known hypercoagulable state

›Reverse anticoagulation only for hemorrhagic shock or the need for emergent or neuraxial surgery

›Do not reflexively reverse a hemodynamically stable patient with a closed fracture, because rebound thrombosis and prosthetic valve risk are real

›Warfarin with major bleeding: 4-factor prothrombin complex concentrate 25 to 50 units per kg by INR and weight, plus vitamin K 10 mg IV by slow infusion

›Dabigatran: idarucizumab 5 g IV given as two 2.5 g doses

›Apixaban or rivaroxaban: andexanet alfa, low-dose regimen 400 mg IV bolus then 4 mg per minute for up to 120 minutes, or high-dose 800 mg bolus then 8 mg per minute, chosen by agent, dose, and interval

›4-factor prothrombin complex concentrate 50 units per kg if andexanet alfa is unavailable

›Antiplatelet agents: one apheresis platelet unit only for life-threatening bleeding or emergent neurosurgery, not routinely

›Recheck for a bleeding source outside the thigh

›Retroperitoneal extension with pelvic or acetabular involvement

›Non-contrast head CT if anticoagulated and any reported head strike or loss of consciousness

Fat embolism and the decompensating elderly faller

›Recognize fat embolism syndrome as a clinical diagnosis

›Hypoxemia, an acute confusional state, and a petechial rash over the axillae, conjunctivae, and chest

›Onset typically 12 to 72 hours after a femoral or long-bone fracture

›Supportive care with oxygen, lung-protective ventilation if intubated, and early fracture stabilization

›Corticosteroids are not recommended for established fat embolism syndrome

›Treat the frail patient who deteriorates after arrival as undifferentiated shock

›Hemorrhage, sepsis from an infected prosthesis, pulmonary embolism, myocardial infarction, and medication effect all present similarly here

›Bedside echocardiography, ECG, lactate, and repeat hemoglobin narrow the differential quickly

›Airway management in the frail hip or femur fracture patient

›Anticipate aspiration risk, dentition loss, and an exaggerated hemodynamic response to induction

›Reduce induction agent doses by 30 to 50 percent and have a vasopressor and fluid ready

›Ketamine 1 mg per kg IV or etomidate 0.15 to 0.3 mg per kg IV are reasonable induction choices

›Reduce further if hypovolemic or cachectic

02History/hx49

Injury mechanism and prior fracture history

›Mechanism and energy

›A ground-level fall or a twist in an osteoporotic postoperative patient is the usual story

›A high-energy mechanism should prompt a full trauma evaluation regardless of the prosthesis

›Pain or a pop with no fall suggests a pathologic fracture through osteolysis or infection

›Onset during or immediately after arthroplasty points to a fracture created at the index surgery

›Symptom onset and progression

›Thigh or groin pain that predated the fall by weeks suggests pre-existing implant loosening

›Start-up pain on rising from a chair is a classic symptom of a loose femoral stem

›Night pain, rest pain, fevers, or sweats raise periprosthetic joint infection

›Prior fractures and falls

›Number and circumstances of falls in the last year

›Previous fragility fractures at any site

›Prior periprosthetic or peri-implant fracture on the same or the opposite limb

›Function immediately before injury

›Community ambulator, household ambulator, or transfers only

›Use of a cane, walker, or wheelchair at baseline

›Weight-bearing status if there was recent surgery on the limb

Implant and functional history

›Prosthesis details

›Which joint, which side, and the date of the index arthroplasty

›Primary versus revision implant, and how many prior revisions

›Cemented versus cementless fixation if known

›Operating surgeon and hospital, to retrieve the operative note and the implant record

›Prior implant problems

›Prior dislocation, periprosthetic infection, or wound healing problem

›Known osteolysis, polyethylene wear, or radiographic loosening on surveillance films

›Recent manipulation, injection, or aspiration of the joint

03Physical Exam/exam40

Primary survey and hemodynamic assessment

›Vital sign interpretation

›Persistent heart rate above 100 despite analgesia suggests hemorrhage, embolism, or sepsis

›A normal heart rate on beta blockade does not exclude blood loss

›Target oxygen saturation 92 to 96 percent for most adults

›Target 88 to 92 percent with COPD or chronic hypercapnia

›Temperature below 36 degrees Celsius promotes coagulopathy and should be actively corrected

›Perfusion assessment

›Capillary refill, a skin temperature line, and mentation as end-organ markers

›Reassess after every analgesic and every fluid or blood bolus

›Signs of occult injury elsewhere

›Scalp and facial injury, especially with anticoagulation

›Chest wall tenderness and abdominal tenderness from the fall

›Contralateral hip and wrist, common sites of a simultaneous fragility fracture

Limb, soft tissue, and wound assessment

›Deformity and length

›Shortening and external rotation with a periprosthetic hip fracture

›Visible angulation or a mobile segment at the level of a stem tip or a knee component

›Effusion or hemarthrosis of a replaced knee

›Skin and open injury

›Any breach of skin over the fracture defines an open fracture until proven otherwise

›Tension blisters, fracture blisters, and pressure areas over the heel and sacrum

›Prior surgical scars and their condition, as they affect the operative approach

›Compartment assessment

›Thigh compartment syndrome is rare but reported with comminuted or interprosthetic fractures

›Pain out of proportion, a tense compartment, and pain on passive stretch warrant compartment pressure measurement

›A regional block can mask early compartment syndrome, so document a pre-block exam

›Joint stability where relevant

04Differential Diagnosis/ddx43

Fracture patterns and implant complications

›Periprosthetic fracture around a hip prosthesis

›Greater or lesser trochanteric avulsion

›Fracture at or just distal to the femoral stem tip

›Fracture well below the stem

›Acetabular periprosthetic fracture, often subtle on plain films

›Periprosthetic fracture around a knee prosthesis

›Supracondylar distal femoral fracture, the most common knee pattern

›Proximal tibial periprosthetic fracture

›Periprosthetic patellar fracture, often with extensor mechanism disruption

›Fractures around other arthroplasties

›Periprosthetic humeral fracture around a shoulder or elbow replacement

›Periprosthetic fracture around an ankle replacement

›Implant complications that mimic or accompany fracture

›Aseptic loosening without a discrete fracture line

›Prosthetic dislocation

›Periprosthetic osteolysis with an impending pathologic fracture

›Insufficiency fracture of adjacent bone such as the pubic rami or sacrum

Pathologic and infected bone

›Periprosthetic joint infection weakening bone

›A fracture with little or no trauma, especially with a prior wound problem

›Fever, rest pain, effusion, a sinus tract, or elevated inflammatory markers

›Aspiration for cell count, differential, crystal analysis, and culture before antibiotics unless septic

›Metastatic or primary bone tumor

›Known malignancy, particularly breast, prostate, lung, renal, thyroid, and myeloma

›A lytic or blastic lesion, cortical destruction, or a soft tissue mass on imaging

›Do not internally fix a suspected pathologic tumor fracture before staging and biopsy planning

›Atypical femoral fracture

05Laboratory Tests/lt28

Perioperative and hemorrhage panel

›Blood count and transfusion preparation

›Complete blood count on arrival for baseline anemia

›Repeat hemoglobin at 4 to 6 hours with a large fracture hematoma or ongoing tachycardia

›An initial hemoglobin can be normal before haemodilution, so a normal first value does not exclude significant bleeding

›Type and screen for every patient, crossmatch two units for comminuted, interprosthetic, or revision-level injuries

›Group and hold a clot sample for the operating room

›Coagulation assessment

›INR and activated partial thromboplastin time in every anticoagulated patient

›Fibrinogen with major bleeding or massive transfusion

›A specific anti-Xa assay where available when the agent or timing is uncertain

›A normal INR and activated partial thromboplastin time do not exclude a therapeutic direct oral anticoagulant level

›Organ function and perfusion

›Creatinine and estimated GFR to dose enoxaparin, analgesics, and contrast

›Potassium, corrected calcium, magnesium, and phosphate before operative planning

›Point-of-care glucose, and venous lactate above 2 mmol/l prompts a search for occult hypoperfusion or sepsis

Infection and metabolic bone workup

›Inflammatory markers and cultures when infection is possible

›C-reactive protein and erythrocyte sedimentation rate, interpreted against the postoperative timeline

›Procalcitonin does not exclude periprosthetic joint infection and should not delay aspiration

›Blood cultures before antibiotics if febrile or septic

›Joint aspiration analysis when infection is suspected

›Synovial white cell count and neutrophil percentage

›Gram stain, aerobic and anaerobic culture, and a sample held for extended culture

›Crystal analysis to exclude a concurrent crystal arthropathy

›Metabolic bone screen to guide secondary fracture prevention

›25-hydroxyvitamin D, corrected calcium, phosphate, and alkaline phosphatase

›Parathyroid hormone, thyroid-stimulating hormone, and renal function

06Diagnostic Tests/dt71

Radiographs

›Plain radiographs are the first-line study

›Full-length anteroposterior and lateral views of the entire prosthesis

›Include the joint above and the joint below the implant on the same film

›Dedicated views of the pelvis for a hip prosthesis and of the knee for a knee prosthesis

›Findings that define management

›Fracture location relative to the stem tip or the femoral or tibial component

›Signs of implant loosening: a radiolucent line wider than 2 mm, component subsidence, cement mantle fracture, or a pedestal

›Osteolysis, cortical thinning, and bone stock at the planned fixation site

›Anterior femoral cortical notching greater than 3 mm predisposes to supracondylar periprosthetic fracture after knee replacement

›Comparison and follow-up films

›Compare with the earliest available postoperative film to judge acute change

›Repeat radiographs after splinting to confirm alignment

›Contralateral limb imaging

›Image the opposite femur if an atypical femoral fracture is suspected

›An incomplete lateral cortical lucency on the other side warrants orthopedic referral

Scoring Systems

›Vancouver classification for periprosthetic femoral fractures around a hip stem

›Type A: fracture of the trochanteric region, subdivided into greater and lesser trochanter

›Type B: fracture around or just below the stem

›B1: stem well fixed

›B2: stem loose but adequate bone stock

›B3: stem loose with poor proximal bone stock

›Type C: fracture well below the tip of the stem, treated independently of the hip implant

›Type B is the most common group, and distinguishing B1 from B2 often requires intraoperative testing of the stem

›Unified Classification System for periprosthetic fractures

›Applies one framework across all bones and joints, using bone segment, implant fixation, and bone stock

›Useful when a fracture involves more than one bone or an interprosthetic segment

›Rorabeck and Lewis classification for supracondylar femoral fractures around a knee replacement

›Type 1: undisplaced with an intact prosthesis

›Type 2: displaced with an intact prosthesis

›Type 3: displaced or undisplaced with a loose or failing prosthesis

›Frailty and risk scores that guide perioperative care

›Clinical Frailty Scale to frame goals of care and expected recovery

›Nottingham Hip Fracture Score for 30-day mortality estimation in the hip fracture pathway these patients follow

›Revised Cardiac Risk Index for perioperative cardiac risk

›CT of the involved bone and joint

›Clarifies fracture configuration, comminution, and intra-articular extension

›Assesses acetabular and pelvic discontinuity behind a hip socket

›Assesses the coronal Hoffa fragment in distal femoral fractures around a knee

›Metal artifact reduction sequences improve visualization near the implant

›CT for occult fracture

›Indicated when radiographs are negative but pain and inability to bear weight persist

›Also clarifies suspected implant loosening when plain films are equivocal

›CT angiography of the limb

›Indicated for absent or asymmetric distal pulses, an expanding hematoma, or a bruit

›Obtain in parallel with vascular surgery consultation rather than sequentially

›CT of other regions driven by the fall

›Non-contrast head CT for anticoagulation with head strike or altered mental status

›Cervical spine CT if there is midline tenderness or a distracting injury

MRI

›MRI is the most sensitive test for a radiographically occult periprosthetic or periarticular fracture

›Detects trabecular fracture lines and bone marrow edema when CT is equivocal

›Metal artifact reduction protocols are required near the prosthesis

›MRI for alternative diagnoses

›Insufficiency fracture of the sacrum or pubic rami mimicking hip pain

›Abductor or extensor mechanism tendon tear

›A soft tissue mass or marrow replacement suggesting tumor

›Practical limitations

›Limited availability out of hours and long acquisition times in a patient in pain

›Should not delay operative fixation of a displaced fracture already evident on plain films

Ultrasound

›Point-of-care ultrasound at the bedside

›Knee or hip joint effusion and ultrasound-guided aspiration

›Quadriceps and patellar tendon integrity when the extensor mechanism is in question

›A large thigh hematoma and a rough estimate of its size

›Vascular ultrasound

›Compression ultrasound for suspected deep vein thrombosis

›Arterial duplex when acute limb ischemia is considered and CT angiography is not immediately available

›Ultrasound to guide regional anesthesia

›Real-time guidance for a fascia iliaca or femoral nerve block improves success

›Guidance lowers the local anesthetic volume needed and the risk of intravascular injection

›Focused cardiac and lung ultrasound

›Assess volume status and exclude a pericardial effusion in the hypotensive patient

›B-lines or a new effusion when fat embolism or pulmonary edema is suspected

07Disposition/dispo39

Admission and consultation

›Almost all periprosthetic fractures require admission under orthopedics

›Displaced fractures, any implant loosening, and inability to mobilize

›Non-displaced trochanteric fractures still warrant admission for pain control and a mobilization assessment

›Orthogeriatric co-management from admission

›Shared care lowers mortality, delirium, and length of stay in this fracture population

›Early medical optimization, bone health review, and a falls assessment

›Additional consultations as indicated

›Vascular surgery for vascular injury

›Infectious diseases when periprosthetic joint infection is confirmed or likely

›Anesthesia preoperative clinic and internal medicine for complex comorbidity

›Palliative care when operative fixation is not aligned with goals of care

›Reason for a non-operative admission pathway

›A stable, minimally displaced fracture with an intact well-fixed implant

›A patient able to mobilize with physiotherapy and with adequate home support

Operative urgency and timing

›Emergent operative indications

›Open fracture requiring debridement, ideally within 24 hours

›Vascular injury or limb-threatening ischemia

›Compartment syndrome

›Fracture with sepsis from an infected prosthesis needing source control

›Early surgery for the remainder

›Aim for definitive fixation or revision within 24 to 48 hours, as in the native hip fracture pathway

›Delay beyond 48 hours is associated with higher mortality and complications

›Acceptable reasons for short delay: correcting anticoagulation, active cardiac ischemia, uncontrolled sepsis, severe anemia

›Preoperative preparation that can start in the emergency department

›Analgesia, fluid and transfusion targets, and an anticoagulation plan

›Consent discussion including goals of care and expected function

08Treatment/t165

Analgesia and regional anesthesia

›Regional block is first-line and opioid-sparing

›Ultrasound-guided fascia iliaca compartment block or femoral nerve block for hip and femoral shaft fractures

›Adductor canal block for distal femoral and knee periprosthetic fractures to preserve quadriceps strength

›Ropivacaine 0.2 percent, 30 to 40 ml for a fascia iliaca block

›Maximum ropivacaine 3 mg per kg

›Bupivacaine 0.25 percent is an alternative with a maximum of 2 mg per kg

›Document a neurovascular and compartment exam before the block

›Have 20 percent lipid emulsion immediately available for local anesthetic systemic toxicity

›Give 1.5 ml per kg IV as a bolus over 1 minute

›Follow with an infusion of 0.25 ml per kg per minute

›Repeat the bolus once or twice and double the infusion rate for persistent cardiovascular collapse

›Maximum recommended dose about 12 ml per kg

›Multimodal non-opioid base

›Acetaminophen 1 g IV or oral every 6 hours, maximum 4 g in 24 hours

›Maximum 3 g in 24 hours if under 50 kg, frail, or with hepatic impairment or high alcohol use

›Opioids by careful titration

›Morphine 1 to 2 mg IV every 5 to 10 minutes titrated to effect

›Reduce the dose by 50 percent and lengthen the interval if age over 75 or estimated GFR under 30 ml/min

›Fentanyl 25 to 50 mcg IV every 5 minutes is preferred when renal function is poor

›Oxycodone 2.5 to 5 mg oral every 4 to 6 hours as needed once tolerating oral intake, starting at 2.5 mg if over 75

›Start a stimulant laxative such as senna 8.6 to 17.2 mg oral at night with any opioid course

›Ondansetron 4 mg IV for opioid-associated nausea

›Agents to avoid or use with caution

›Avoid NSAIDs such as ketorolac 10 to 15 mg IV in the older adult with hypovolemia, chronic kidney disease, or bleeding risk, and because of a possible adverse effect on fracture healing

›Avoid meperidine 25 to 50 mg IV because normeperidine accumulation causes delirium and seizures in older adults

›Use gabapentinoids such as gabapentin 100 mg oral at night sparingly because of sedation and fall risk in older adults

›Avoid routine benzodiazepines such as diazepam 2 mg oral for muscle spasm because of delirium risk

Hemodynamic resuscitation and transfusion

›Access and monitoring

›Two large-bore intravenous cannulae and continuous cardiac and oximetry monitoring

›Reassess blood pressure, heart rate, mentation, and urine output after every bolus

›Fluids

›Balanced crystalloid in 250 to 500 ml aliquots titrated to perfusion, not a fixed large volume

›Older adults with diastolic dysfunction or chronic kidney disease decompensate into pulmonary edema with over-resuscitation

›Blood products

›Transfuse red cells to a hemoglobin threshold of 70 g/l in the stable patient

›Use a threshold of 80 g/l with acute coronary syndrome, active myocardial ischemia, or symptomatic anemia

›Activate the massive transfusion protocol for the rare exsanguinating comminuted or interprosthetic fracture

›Tranexamic acid 1 g IV over 10 minutes for significant bleeding, avoided with thrombosis within 3 months or a known hypercoagulable state

›Blood pressure targets and vasopressor bridge

›Maintain systolic blood pressure at least 90 to 100 mmHg or mean arterial pressure at least 65 mmHg

›Aim higher with chronic hypertension, known cerebrovascular disease, or chronic kidney disease

›Norepinephrine peripheral infusion started at 0.05 mcg per kg per minute if hypotension persists despite volume

›Titrate by 0.02 to 0.05 mcg per kg per minute every 5 minutes to a mean arterial pressure of at least 65 mmHg

›Slow to smaller increments as the target is approached to avoid overshoot

›Check blood pressure every 5 minutes while titrating, continuously if an arterial line is in place

›Wean as volume and red cells are replaced, because ongoing pressor need means unrecognized hemorrhage

›Do not use a pressor to substitute for blood in a bleeding patient

›When resuscitation is not working

›Persistent tachycardia or a falling hemoglobin despite transfusion means ongoing bleeding until proven otherwise

›Reimage for retroperitoneal, pelvic, or acetabular extension and obtain CT angiography of the limb

›Involve orthopedics and vascular surgery for operative or endovascular hemostasis

›Reconsider fat embolism, pulmonary embolism, myocardial infarction, and sepsis from an infected prosthesis

›Adjuncts

›Keep the patient normothermic above 36 degrees Celsius with active warming

›Replace ionized calcium after multiple units of blood, because citrate binds calcium

›Watch the ECG after massive transfusion for peaked T waves of hyperkalemia and a prolonged QT from hypocalcemia

Anticoagulation and venous thromboembolism prevention

›Mechanical prophylaxis from arrival

›Intermittent pneumatic compression on the uninjured leg unless contraindicated

›Early mobilization once fixation allows

›Pharmacologic prophylaxis

›Enoxaparin 40 mg subcutaneously once daily, reduced to 30 mg once daily if creatinine clearance under 30 ml/min

›Unfractionated heparin 5000 units subcutaneously every 8 to 12 hours where renal function is poor or rapid reversibility is needed

›Time the first dose with the surgical team around the operative window

›Timing around neuraxial anesthesia and surgery

›Withhold a prophylactic enoxaparin dose for at least 12 hours before a neuraxial procedure

›Withhold a therapeutic low molecular weight heparin dose for at least 24 hours before a neuraxial procedure

›Hold direct oral anticoagulants 24 to 48 hours before surgery, longer with reduced creatinine clearance

›Resuming or reversing therapeutic anticoagulation

›Do not fully reverse a stable closed-fracture patient purely for admission

›Bridge only patients at very high thrombotic risk such as a mechanical mitral valve or recent venous thromboembolism

›Restart therapeutic anticoagulation after surgery only when the surgeon confirms hemostasis

Fracture immobilization and traction

›Splinting and positioning

›Long-leg splint or knee immobilizer for distal femoral and knee periprosthetic fractures

›Pillow support and log-roll precautions for periprosthetic hip fractures

›Elevate the limb to limit swelling while keeping pressure off the heel

›Skin traction

›Routine skin traction is not recommended and does not improve pain or outcomes

›It causes pressure injury and peroneal nerve palsy in older adults

›Pressure injury and skin care

›A pressure-redistributing mattress and 2-hourly repositioning from arrival

›Protect the heels off the bed and inspect the sacrum

›Reduction in the emergency department

›Gross deformity with vascular compromise is gently realigned and splinted

›Definitive reduction occurs in the operating room, not the emergency department, for most patterns

Open fracture and periprosthetic infection

›Open periprosthetic fracture

›Remove gross contamination, photograph the wound, and apply a saline-soaked dressing

›Do not repeatedly expose the wound in the emergency department

›Cefazolin 2 g IV every 8 hours, increased to 3 g every 8 hours if over 120 kg

›Add gentamicin 5 mg per kg IV once daily for a highly contaminated or Gustilo type III wound

›Add penicillin G 3 to 4 million units IV every 4 hours or metronidazole 500 mg IV every 8 hours for farmyard or gross fecal contamination

›Tetanus-diphtheria toxoid 0.5 ml IM and tetanus immunoglobulin per immunization status

›Debridement in the operating room, ideally within 24 hours

›Suspected periprosthetic joint infection

›Aspirate the joint for cell count, differential, crystals, Gram stain, and culture before antibiotics

›Withhold empiric antibiotics in the stable patient until cultures are obtained

›If septic, draw blood cultures then start vancomycin 15 to 20 mg per kg IV every 8 to 12 hours plus cefepime 2 g IV every 8 hours

›Involve the revision arthroplasty and infectious diseases services early, as management is debridement or staged revision

Medical optimization and delirium prevention

›Delirium prevention bundle

›Orient frequently, restore glasses and hearing aids, promote sleep, and mobilize early

›Avoid physical restraints, unnecessary urinary catheters, and tethering lines

›Review and stop anticholinergic and sedative-hypnotic medications

›Treat pain adequately, because undertreated pain is itself a delirium trigger

›Reserve haloperidol 0.25 to 0.5 mg oral or IV for dangerous agitation, repeated after 30 to 60 minutes if needed

›Avoid in Parkinson disease and Lewy body dementia and if the corrected QT interval exceeds 500 ms

›Perioperative medical care

›Continue beta blockers and statins, and hold ACE inhibitors and diuretics on the morning of surgery if hypovolemic

›Manage diabetes to a perioperative glucose target of 6 to 10 mmol/l, avoiding values under 4 mmol/l

›Accept a somewhat higher range in long-standing poorly controlled diabetes to avoid relative hypoglycemia

›Screen and treat for anemia, volume depletion, and electrolyte disturbance

›Ensure adequate protein intake and early mobilization

›Prophylaxis and supportive care

›Stress ulcer prophylaxis only with recognized ICU-level risk factors, not routinely

›Aspiration precautions, early oral intake, and laxatives with opioids

›Early urinary catheter removal to limit infection and delirium

›Bone health and falls, initiated in hospital

›Replete vitamin D and ensure a total calcium intake of about 1000 to 1200 mg daily

›Start an antiresorptive such as zoledronic acid 5 mg IV once yearly or denosumab 60 mg subcutaneously every 6 months once vitamin D replete, timed with the treating team

›Occupational therapy home hazard assessment and a physiotherapy falls program

Iatrogenic harm from routine emergency interventions

›Intubation and induction

›Frailty, aspiration risk, and exaggerated hypotension: reduce induction doses by 30 to 50 percent and stabilize the limb before positioning

›Reversal of anticoagulation for theatre is an anesthetic and surgical decision, not an automatic emergency department action

›Procedural sedation

›Oversedation causes delirium, hypotension, and respiratory depression

›A regional block is preferred to deep sedation for splinting or reduction, and benzodiazepines are avoided

›Fluid loading

›Large fixed-volume crystalloid causes pulmonary edema in elderly diastolic dysfunction and chronic kidney disease

›Give blood rather than crystalloid when the problem is hemorrhage

›Oxygen

›Target 92 to 96 percent, or 88 to 92 percent in COPD or chronic hypercapnia, rather than liberal high-flow oxygen in a saturated patient

›A new oxygen requirement should trigger a search for fat embolism, pulmonary embolism, aspiration, or pulmonary edema

›Vasopressors

›Early pressors mask hypovolemia from thigh bleeding

›Restore volume and red cells first, and use peripheral norepinephrine only as a short bridge

›Mechanical circulatory support

›Intra-aortic balloon pump and other mechanical support are not indicated for this condition

›If already in place for cardiac disease, its mandatory anticoagulation conflicts with fracture hematoma bleeding and needs explicit multidisciplinary balancing

›Anticoagulation

›Therapeutic anticoagulation is not indicated acutely for the fracture, whereas prophylactic dosing is

›Do not reflexively reverse a stable closed fracture; reserve reversal for shock or emergent or neuraxial surgery

›Fibrinolysis

›An acute long-bone fracture with a large hematoma is a contraindication to systemic thrombolysis

›If a concurrent ST-elevation myocardial infarction or acute ischemic stroke is present, choose mechanical reperfusion over a lytic agent

›Analgesia

›NSAIDs risk acute kidney injury, gastrointestinal bleeding, platelet inhibition worsening the hematoma, and possibly impaired bone healing

›Opioid excess causes delirium, respiratory depression, and ileus, so titrate and pair with a bowel regimen

›Meperidine is contraindicated in older adults

›Urinary catheterization and immobilization

›Catheters add catheter-associated infection and delirium, so remove them early

›Bed rest adds venous thromboembolism, deconditioning, pneumonia, and pressure injury, so mobilize as soon as fixation allows

Definitive operative strategy

›The implant fixation status drives the operation

›Well-fixed implant such as Vancouver B1 or Rorabeck type 1 or 2: open reduction and internal fixation with a locking plate, cerclage cables, and sometimes a cortical strut allograft

›Loose implant such as Vancouver B2: revision to a longer stem that bypasses the fracture

›Loose implant with poor bone stock such as Vancouver B3: proximal femoral replacement or an allograft-prosthesis composite

›Fracture below the implant such as Vancouver type C: plate fixation that spans to the implant tip to avoid a new stress riser between constructs

›Trochanteric and patellar patterns

›Most stable trochanteric fractures are treated non-operatively with protected weight-bearing

›Displaced trochanteric fractures with abductor compromise may need a claw plate or cable grip

›Periprosthetic patellar fractures with an intact extensor mechanism and a stable component are often non-operative

›Distal femoral options around a knee

›Retrograde intramedullary nail if the femoral component has an open box design

›Lateral distal femoral locking plate

›Distal femoral replacement for a loose component or unreconstructable bone

›Weight-bearing and rehabilitation expectations

›Protected weight-bearing is common for 6 or more weeks depending on the construct

›Non-operative management is reserved for truly stable patterns because prolonged recumbency carries high mortality in this group

09Special Populations/sp59

Pregnancy

›Epidemiology and context

›Rare, because most arthroplasty recipients are older, but seen in young patients with juvenile idiopathic arthritis, osteonecrosis, or developmental hip dysplasia

›Pregnancy and the puerperium independently raise venous thromboembolism and fall risk

›Imaging

›Plain radiographs of the femur or knee deliver a negligible fetal dose, well under 1 mGy, and should not be withheld

›CT of the pelvis delivers a higher fetal dose in the range of tens of mGy; use shielding and justification, but deterministic fetal effects are not expected below about 100 mGy

›MRI without gadolinium is preferred for an occult fracture after the first trimester

›After about 20 weeks, tilt the patient left laterally during supine imaging and procedures to avoid aortocaval compression

›Analgesia

›Acetaminophen 1 g oral every 6 hours, maximum 4 g in 24 hours, is the preferred base analgesic

›Avoid NSAIDs, particularly after 20 weeks, because of oligohydramnios and premature ductal constriction

›Short-course opioids are acceptable with neonatal monitoring for withdrawal if used near delivery

›Regional nerve blocks with standard weight-based local anesthetic maxima are preferred

›Thromboprophylaxis and anticoagulation

›Low molecular weight heparin is the agent of choice: enoxaparin 40 mg subcutaneously once daily for prophylaxis, weight-adjusted with anti-Xa monitoring if therapeutic

›Avoid warfarin because of teratogenicity and direct oral anticoagulants because of placental transfer and limited data

›Do not omit prophylaxis, because peripartum venous thromboembolism risk is high

›Coordination

›Joint orthopedic, obstetric, and anesthetic planning

›Continuous fetal monitoring during and after surgery once the fetus is viable

Geriatric

›This is the core population and mirrors the native hip fracture cohort

›One-year mortality after a postoperative periprosthetic femoral fracture is approximately 10 to 13 percent

›Thirty-day mortality is approximately 3 to 6 percent

›Loss of independent mobility and new institutionalization are common outcomes

›Physiologic vulnerability

›Reduced cardiac and renal reserve means both hypovolemia and fluid overload are poorly tolerated

›A blunted tachycardic response on beta blockers masks hemorrhage

›Polypharmacy and altered pharmacokinetics require reduced opioid and sedative dosing

›Comprehensive geriatric management

›Orthogeriatric co-management, a delirium prevention bundle, and early mobilization

›Beers criteria review with removal of anticholinergics and long-acting sedatives

›Nutritional supplementation and pressure injury prevention

›Goals of care

›Discuss expected function, operative risk, and the poor outcomes of non-operative management before committing to a plan

›Even palliative patients often benefit from fixation purely to allow transfers and comfort

Pediatrics

›Periprosthetic and peri-implant fractures in children are uncommon

›Around tumor endoprostheses such as a distal femoral replacement after osteosarcoma resection

›Around expandable or growing implants and limb reconstruction systems

›Around retained fracture fixation such as plates, flexible nails, and screws, which act as stress risers

›Assessment

›A fracture pattern inconsistent with the stated mechanism warrants evaluation for non-accidental injury in the young child

›Assess physeal involvement in any child with open growth plates

›Neurovascular exam as for adults, with attention to the peroneal nerve around the knee

›Analgesia and sedation dosing

›Acetaminophen 10 to 15 mg per kg oral or IV every 6 hours, maximum 75 mg per kg per day and not exceeding 4 g

›Morphine 0.05 to 0.1 mg per kg IV every 2 to 4 hours titrated to effect

›Fentanyl 0.5 to 1 mcg per kg IV every 30 to 60 minutes for procedures

›Verify against current pediatric guideline before use

›Local anesthetic for a regional block dosed strictly by weight, ropivacaine maximum 3 mg per kg

›Resuscitation dosing

›Isotonic crystalloid bolus 10 to 20 ml per kg reassessed after each bolus

›Verify against current pediatric guideline before use

›Packed red cells 10 ml per kg for hemorrhagic shock

›Verify against current pediatric guideline before use

›Tranexamic acid 15 mg per kg IV over 10 minutes, maximum 1 g, if there is significant bleeding

›Verify against current pediatric guideline before use

›Disposition

›Manage at a pediatric orthopedic centre

›Involve the original reconstruction or oncology team early

10Background/b44

Epidemiology

›Incidence

›Periprosthetic femoral fracture occurs after roughly 0.1 to 2 percent of primary total hip replacements and up to about 4 percent after revision hip replacement

›Supracondylar femoral periprosthetic fracture occurs after roughly 0.3 to 2.5 percent of total knee replacements

›Periprosthetic tibial and patellar fractures are each under about 2 percent, with patellar fractures more common after patellar resurfacing

›Periprosthetic fracture is among the three most common reasons for revision after primary hip replacement in national registries

›Trends

›Absolute numbers are rising with the growing volume of primary and revision arthroplasty and an ageing population

›The interprosthetic femur, between a hip and a knee implant, is an increasingly recognized high-risk pattern

›Risk factors

›Female sex, age over 70, and osteoporosis

›Rheumatoid arthritis, chronic corticosteroid use, and osteolysis from polyethylene wear

›Revision implants, cementless femoral stems, and intraoperative cortical perforation or notching

›Neurological disease causing falls, such as Parkinson disease and prior stroke

›Prolonged antiresorptive therapy predisposing to atypical femoral fracture around a stem

›Outcomes

›One-year mortality after a postoperative periprosthetic femoral fracture is approximately 10 to 13 percent, comparable to native hip fracture

›Nonunion, malunion, implant failure, and reoperation rates are higher than for native fractures

Pathophysiology

›Mechanical stress concentration

›The stiff implant creates a modulus mismatch with adjacent osteopenic bone, concentrating stress at the implant tip

›Screw holes, cement mantle defects, cortical perforations, and anterior femoral notching greater than 3 mm are focal stress risers

›The short bone segment between two implants concentrates load and fails with minimal trauma

›Bone loss mechanisms

›Stress shielding after hip replacement causes proximal femoral bone resorption over years

›Polyethylene and metal wear particles drive a macrophage and osteoclast response producing periprosthetic osteolysis

›Implant loosening generates micromotion, an inflammatory membrane, and progressive bone loss

›Injury mechanism

11Patient Discharge Instructions/pdi37

Candidates for non-operative outpatient management

›Only a minority are suitable for discharge without admission

›An isolated, minimally displaced greater trochanteric fracture with a well-fixed implant

›A periprosthetic patellar fracture with an intact extensor mechanism and a stable component

›The patient can mobilize safely with physiotherapy and has adequate home support

›Requirements before discharge

›Orthopedic review has occurred and outpatient follow-up is booked within 1 week

›Radiographs are confirmed to show a stable pattern with no implant loosening

›Adequate analgesia is achieved and the patient can walk with an aid

›A thromboprophylaxis plan is documented and understood

›Reasons to return rather than discharge

›Increasing deformity or inability to bear weight

›Uncontrolled pain or any change in sensation, movement, or circulation of the foot

copy discharge instructions

›Why this matters

›You have a break in the bone next to your joint replacement, and the bone around an implant is weaker and heals slowly

›Even if surgery is not needed now, this fracture can shift, so close follow-up is essential

›Activity and weight-bearing

›Put weight through the leg only as the orthopedic team has told you, using the walker or crutches provided

›Do not drive until the orthopedic team says it is safe

›Keep the leg elevated when resting, but keep the heel off the bed to protect the skin

›Medicines

›Take acetaminophen 1 g up to four times a day, and no more than 4 g in 24 hours; use no more than 3 g in 24 hours if you weigh under 50 kg, are frail, or have liver problems

›Use the prescribed oxycodone 2.5 to 5 mg every 4 to 6 hours only if needed for pain, and not with alcohol or sleeping tablets

›Take a laxative such as senna 8.6 to 17.2 mg at night while using opioid pain medicine to prevent constipation

›Do not take anti-inflammatory medicines such as ibuprofen 400 mg unless your doctor has specifically approved them

›Give yourself the blood-thinning injection exactly as instructed for the number of days specified

›Take your calcium and vitamin D, and attend the bone health clinic appointment, because bone-strengthening treatment lowers your risk of another fracture

12References/r33

Classification systems and orthopedic guidelines

›Duncan CP, Masri BA. Fractures of the femur after hip replacement

›Instructional Course Lectures, American Academy of Orthopaedic Surgeons, 1995

›Original description of the Vancouver classification by fracture site, implant fixation, and bone stock

›Duncan CP, Haddad FS. The Unified Classification System for periprosthetic fractures around or between implants

›The Bone and Joint Journal, 2014

›Rorabeck CH, Taylor JW. Classification of periprosthetic fractures complicating total knee arthroplasty

›Orthopedic Clinics of North America, 1999

›National Institute for Health and Care Excellence. Hip fracture: management, clinical guideline CG124

›National Institute for Health and Care Excellence, last updated 2023

›American Academy of Orthopaedic Surgeons. Management of hip fractures in older adults, clinical practice guideline

›American Academy of Orthopaedic Surgeons, 2021

Perioperative and analgesia evidence

›Carson JL, et al. Liberal versus restrictive transfusion in high-risk patients after hip surgery, the FOCUS trial

›New England Journal of Medicine, 2011

›A restrictive threshold near 80 g/l was not inferior to a liberal strategy in this population

›AABB. Red blood cell transfusion thresholds and storage, clinical practice guidelines

›Journal of the American Medical Association, 2023

›CRASH-2 Collaborators. Tranexamic acid in bleeding trauma patients

›Lancet, 2010

›HIP ATTACK Investigators. Accelerated surgery versus standard care in hip fracture

›Lancet, 2020

›Association of Anaesthetists. Guidelines for the management of hip fractures in older people

›Anaesthesia, 2021

›American Society of Regional Anesthesia and Pain Medicine. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy, fourth edition

›Regional Anesthesia and Pain Medicine, 2018

Bone health, thromboprophylaxis, and infection

›Endocrine Society. Pharmacological management of osteoporosis in postmenopausal women, clinical practice guideline

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed September 13, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.