Background. Peri-prosthetic humerus fractures are relatively uncommon occurrences that can be difficult to manage non-operatively. Locking plate technology has enhanced the surgical management of these fractures. We describe an osteosynthesis technique utilizing a locking plate with eccentrically placed screw holes to place “skive screws” in the proximal end of the plate to achieve fixation around the stem of the implant. Methods. A retrospective review of prospectively collected data was performed for a consecutive series of patients treated with this skive screw technique from May 2011 to September 2014. Seven patients presented with postoperative type B peri-prosthetic humerus fractures. Average follow-up was 24 months. Radiographic analysis was performed on most recent postoperative imaging. Clinical outcomes were assessed using VAS pain, ASES total score, ASES functional score, SST, SANE, range of motion and strength. Results. At an average of follow-up of 24 months, all patients demonstrated fracture healing. Functional outcomes were limited with only two patients achieving forward elevation above 90 degrees and average ASES Function score was 27.5. Pain relief was nearly uniform with an average VAS Pain score of 0.5 (Figure 1). Conclusions. Peri-prosthetic humeral shaft fractures can be successfully treated with hybrid fixation technique using a locking plate with eccentric holes that facilitate placement of proximal “skive screws”. Using this technique, a 100% union rate was observed with excellent pain relief

Introduction. The number of total hip replacements taking place across the UK continues to grow. In an ageing population, with people living longer and placing greater strain on their prostheses, the number of peri-prosthetic femoral fractures is increasing. We studied the economic impact this has on a large university teaching hospital. Method. All patients with a peri-prosthetic femoral fracture between 24/11/2006 and 31/5/2014 were identified using theatre databases. Radiographic and case note analysis was performed for each case. Costings from finance department for implants and in-patient stay were obtained. Results. 90 cases were identified, 58 female and 32 male, with a mean age of 76 (range: 38–91). 86 fractures occurred around total hip replacements, 4 around hemi-arthroplasties. 89 of the cases were managed surgically, 66% undergoing revision and 33% receiving open reduction and internal fixation (ORIF). According to the Vancouver Classification, 3% were Type A, 79% Type B and 18% Type C. The mean length of stay for all fractures was 43 days, ranging from 5 – 179. The mean overall cost of management was £31,370 (range: £6885 – £112,327). Patients with type C fractures had the highest mean length of stay at 53 days and highest overall mean cost of £33,417. Conclusion. When including rehabilitation costs, our study illustrated a mean cost of £31370, roughly four times the NHS tariff of £8552 and significantly greater than the £3702 per case recovered by one UK teaching hospital. This equates to an average £22000 shortfall per case for peri-prosthetic fractures alone at our institution. Although implant costs are greater, treatment with revision where appropriate allows earlier weight bearing, reduced length of stay and rehabilitation costs and lower overall cost

INTRODUCTION. Peri-prosthetic fungal infection is generally considered more difficult to cure than a bacterial infection. Two-stage exchange is considered the gold standard of surgical treatment. A recent study, however, reported a favorable outcome after one stage exchange in selected cases where the fungus was identified prior to surgery. The routine one stage exchange policy for bacterial peri-prosthetic infection involves the risk of identifying a fungal infection mimicking bacterial infection solely on intraoperative samples, i.e. after reimplantation, realizing actually a one stage exchange for fungal infection without pre-operative identification of the responsible fungus, which is considered to have a poor prognosis. We report two such cases of prosthetic hip and knee fungal infection. Despite this negative characteristic, no recurrence of the fungal infection was observed. CASE N°1: A 78 year old patient was referred for loosening of a chronically infected total hip arthroplasty (Staphylococcus aureus and Streptococcus dysgalactiae). One stage exchange was performed. Intraoperative bacterial cultures remained sterile. Two fungal cultures were positive for Candida albicans. Antifungal treatment was initiated for three months. No infection recurrence was observed at three year follow up. CASE N° 2: A 53-year-old patient was referred for loosening of a chronically infected total knee prosthesis (Staphylococcus aureus methicillin susceptible, Klebsiella pneumoniae and Staphylococcus epidermidis). One stage exchange was performed. Intraoperative bacterial cultures remained sterile. Five fungal cultures were positive for Candida albicans. Antifungal treatment was initiated for three months. No infection recurrence was observed at two-year follow-up. DISCUSSION. This experience suggests that eradication of fungal infection of a total hip or knee arthroplasty may be possible after one stage exchange even in cases where the diagnosis of fungal infection was not known before surgery, when the fungus was not identified and its antifungal susceptibility has not been evaluated before surgery. It is however not possible to propose this strategy as a routine procedure. CONCLUSION. We suggest evaluating the results of one stage exchange for peri-prosthetic fungal infection on a larger scale

Introduction: The incidence of Peri-prosthetic fractures is about 1% following Lower limb arthroplasty. The management of these fractures is difþcult,complex,challenging and controversial. Aim of Study: To study the results of Dal- Miles Plating system in Peri-prosthetic fractures. To þnd the difference, if any in the outcome of Transverse vs. Spiral fractures. Material and Methods: 13 patients, who were treated with Dal-Miles plating for periprosthetic fractures in last 4 years in our hospital, were reviewed. There were 7 females and 6 males. Average age of the patients was 73.8 years. Fractures were classiþed according to Vancouver classiþcation. Fractures were also classiþed according to their pattern into Transverse and Spiral Fractures. Results: There was high rate of complications during the postoperative period with half the patients having some complication. (Implant failure-3, malunion-1, Infection-2, Fracture distal to plate-3). All the patients who had Implant failure had transverse type of Fracture. No patient with spiral type fracture had non-union. Conclusions: Treatment of Peri-prosthetic fractures with Dal-Miles Plating is complicated and associated with high rate of complication. Transverse type fractures have high rate of failure (50% in our study) following þxation with Dal-Miles Plating system

Introduction: Heterotopic ossification (HO) is common post total hip replacement. Dual energy x-ray absorptiometery (DXA) is an established technique used to assess peri-prosthetic, bone mineral density (BMD) changes in the femur following surgery. The effect of HO on these measurements has not previously been reported. In this study we investigated the incidence and distribution of HO and the extent to which it affected peri-prosthetic DXA results. Methods: As part of a two-year, prospective, primary cemented THR trial, 137 patients were assessed at six month intervals with DXA as well as anterior-posterior and lateral radiographs. HO was identified from radiographs and then further localised to the seven femoral Gruen zones using DXA subtraction imaging. Results: HO affected at least one Gruen zone in 46% of study patients. The mean BMD in zone 1 dropped to 89% of the postoperative value in unaffected patients by six months whereas it actually increased to 102% in the HO patients (p< 0.001). This 12% difference persisted throughout the duration of the trial. Zone two was affected in 17 patients and a significant gain of 5% was noted in these patients at 12 months (p< 0.05). From observation of AP x-rays alone, 12% of the HO cases would have been missed. HO was found to be significantly associated with male gender and increasing age at time of operation. Surgical approach to the hip also had an effect, osteotomies producing a greater incidence of HO formation. Discussion: HO has a dramatic effect on BMD values determined by DXA. This has not previously been reported and may have affected other peri-prosthetic studies. We recommend careful screening for HO when reporting femoral peri-prosthetic BMD changes

Displaced fractures of the neck of femur are routinely treated in the elderly by either cemented hemiarthoplasty, in the fit, or uncemented hemiarthroplasty, in the less fit. In Scotland the Scottish Intercollegiate Guidelines Network (SIGN) guidelines are followed to identify which patients should have a cemented prosthesis. This is based on cardiovascular status, and the age and fragility of the patient. An uncemented prosthesis should be a final operation. A peri-prosthetic fracture is considered a failure of treatment as the patient then has to undergo an operation with a far greater surgical insult. We looked at all neck of femur fractures over a period of Jan 2007 to June 2010. The number of the peri-prosthetic fractures for uncemented hip hemiarthroplasties was established, and a case note review was carried out. There was 1397 neck of femur fractures. 546 hemiarthroplasties were carried out, of which 183 were cemented, and 363 uncemented. 15 patients (4% of uncemented hemiarthoplasties) had peri-prosthetic fractures. There were no peri-prosthetic fractures in the cemented group, p = 0.004 using Fisher's exact test. The case notes of these patients were analysed. We found there was a common link of significant cardiovascular risk, lack of falls assessment (only 14% of the patients had a completed falls assessment and 21% sustained their fracture during an admission to hospital) and confusion (50% had a degree of dementia that caused significant confusion). Cemented implants should be considered in all patients, especially those who are cognitively impaired or have failed falls assessments; even if the cardiovascular risk is significant. This decision should be made in conjunction with a senior anaesthetist. This is being implemented in our unit and a prospective audit is being carried out over the same time period (July 2010 to Dec 2013) to assess the benefit

Introduction. The management of peri-prosthetic distal femur fractures following TKR (Total Knee Replacement) in the elderly remains a challenge with little or no consensus on the best available treatment. Various methods have been described in the management of these complex fractures. Our study compares the outcome and cost of distal femoral arthroplasty to that of Fixation (Plating/Retrograde Nailing). Methods. We retrospectively reviewed our database for patients admitted with peri-prosthetic distal femoral fractures between 2005–2013 (n=61). The patients were stratified into 2 groups based on method of management. The Distal Femoral Arthroplasty group (Group A) had 21 patients, with a mean age of 78 years (68–90. The Fixation group (Group B) had 40 patients, with a mean age of 74 years, 23 of those had plating of the fracture, while 17 had a retrograde nail inserted. Pain scores, Length of stay, intra-operative blood loss, and weight bearing status, were compared. Functional outcomes were also assessed using Oxford knee scores, KSS scores, VAS pain assessment and range of motion from last follow up appointment. Minimum follow-up was 2 years. Cost analysis was done for both groups, which included implant costs, consumable costs (man power included), theatre utilisation time and length of hospital stay. The calculation was done based on the PbR (payment by results) system and “best practise tariffs 2010–11” utilised by the NHS (National Health Service) in England. Results. In group A, the average surgical time was 116 minutes with mean blood loss of 400 ml. In group B, the mean surgical time was 123 minutes with average blood loss of 800 ml. The mean length of hospital stay in group A was 9 days whereas in group B was 32 days. All patients were fully weight bearing by day 1.5(range 1–3 days) in group A, compared to a mean of 11 weeks in group B. Mean Oxford score was 28 and KSS score was 70 in group A compared to 27 and 68 in group B. The pain score on VAS was 2 for group A and 1.5 for group B. The mean ROM of the knee was 95° in group A and 85° in group B. We had 4 complications in group A. There were 2 deaths due to medical co-morbidities, 1 superficial infection, and 1 DVT. In the fixation group, there were 6 deaths due to medical co-morbidities, 1 failure of fixation, 6 mal-unions, 1 non-union and 2 infections. Overall, the distal femoral arthroplasty procedure costs approximately £10000, and the fixation group costs were on average of £9800. Discussion & Conclusion. Distal femoral arthroplasty allowed early mobilisation, thus avoiding prolonged hospital stay and reducing the risk of inpatient related morbidity. Complication rates were lower than the fixation group and the overall costs were comparable to that of fixation. Distal femoral arthroplasty appears to be a promising alternative treatment to internal fixation in elderly patients with distal femoral peri-prosthetic fractures. With appropriate patient selection, the prosthesis is likely to survive for the duration of patient's lifetime

Introduction: Dual Energy x-ray absorptiometery (DXA) is a useful tool for the assessment of peri-prosthetic bone mineral changes following total joint replacement. In order to assess these changes the precision of the DXA technique must be optimised. While patient positioning is an important factor, the role of the analysis software should also be considered. We developed and applied a new image analysis method to data from the EXPERT-XL fan beam densitometer (LUNAR GE, USA) aiming to improve reproducibility of bone region and tissue type determination by the analysis software. Methods: 60 patients with cemented THR received repeat same day DXA examinations. These were initially analysed strictly according to the manufacturer’s femoral peri-prosthetic protocol. A modification of this protocol was attempted allowing further small corrections to the tissue typing by the operator. The scans were then reanalysed using locally developed image analysis to accurately determine the bone, prosthesis and Gruen zone boundaries. The coefficient of variation (CV) was calculated from the differences of the repeat examinations for each of the seven Gruen zones and for the whole peri-prosthetic region. Results: The average zone CV was 5%. The poorest was zone 1 (10%) and best zone 4 (2%). With the operator corrections there was an overall 4% improvement. With our method there was an overall 40% reduction in variation (average CV 3%, maximum 4%, minimum 2%). The whole region CV was 3.1% for the standard method 2.7% modified and 1.3% for our method. Discussion: Our method significantly improved the reproducibility of EXPERT analysis. This study demonstrates the high dependency of DXA precision on robust regional analysis

Peri-prosthetic fractures above a TKA are becoming increasingly more common, and typically occur at the junction of the anterior flange of the femoral component and the osteopenic metaphyseal distal femur. In the vast majority of cases the TKA is well fixed and has been functioning well prior to fracture. For loose components, revision is typically indicated. Typically a megaprosthesis is required. Well-fixed components, internal fixation is preferred. Fixation options include retrograde nailing or lateral plating. Nails are typically considered in arthroplasties that allow intercondylar access (“open box PS” or CR implants) and have sufficient length of the distal fragment to allow multiple locking screws to be used. This situation is rare, as most distal fragments are quite short. If a nail is chosen, use of a long nail is preferred, since it allows the additional fixation and alignment that diaphyseal fill affords. Short nails should be discouraged since they can “toggle” in the meta-diaphysis and do not engage the diaphysis to improve coronal alignment. Plates can be used with any implant type and any length of distal fragment. The challenge with either fixation strategy is obtaining stable fixation of the distal fragment while maintaining length, alignment, and rotation. Fixation opportunities in the distal fragment can be limited due to obstacles caused by femoral component lugs, boxes, stems, cement mantles, and areas of stress shielding or osteolysis. Modern lateral locked plates can be inserted in a biologically friendly submuscular extra-periosteal fashion. More recent developments with polyaxial locked screws (that allow angulation prior to end-point locking) may offer even more versatility when distal fragment fixation is challenging. The goal of fixation is to obtain as many long locked screws in the distal fragment as possible. High union rates have been reported with modern locked plating techniques, however, biplanar fluoroscopic vigilance is required to prevent malalignments, typically valgus, distraction, and distal fragment hyperextension

With an increasing ageing population and a rise in the number of primary hip arthroplasty, peri-prosthetic fracture (PPF) reconstructive surgery is becoming more commonplace. The Swedish National Hip Registry reported that, in 2002, 5.1% of primary total hip replacements required revision due to PPF. Laboratory studies have indicated that age, bone quality and BMI all contribute to an increased risk of PPF. Osteolysis and aseptic loosening contribute to the formation of loosening zones as described by Gruen, with subsequent increased risk of fracture. The aim of the study was to identify significant risk factors for PPF in patients who have undergone primary total hip replacement (THR). Logbooks of three Consultant hip surgeons were filtered for patients who had THR-PPF fixation subsequent to trauma. Risk factors evaluated included sex, age, bone density (Singhs index), loosening zones, Vancouver classification, prosthesis stem angle relative to the axis of the femur, and length of time from THR to fracture. A control group of uncomplicated primary THR patients was also scrutinised. Forty-six PPF were identified representing 2.59% of THR workload. The male: female ratios in both groups were not significantly different (1:1.27 and 1:1.14 respectively). Average age of PPF was 72.1, which was significantly older than the control group (54.7, p>0.05). The commonest type of PPF was Vancouver type B. Whilst stem position in the AP plane was similar in both groups, in lateral views the PPF stem angle demonstrated significant antero-grade leg position compared to the non-PPF group (p.0.05). The PPF group demonstrated a greater number of loosening zones in pre-fracture radiographs compared to the control group (2.59 and 1.39 respectively, p>0.05). Our workload from PPF reflects that seen in Europe. Age, stem position and the degree of stem loosening appear to contribute to the risk of a peri-prosthetic fracture

Peri-prosthetic fractures above a total knee arthroplasty (TKA) are becoming increasingly more common, and typically occur at the junction of the anterior flange of the femoral component and the osteopenic metaphyseal distal femur. In the vast majority of cases the TKA is well-fixed and has been functioning well prior to fracture. For loose components, revision is typically indicated. Typically a megaprosthesis is required. For well-fixed components, internal fixation is preferred. Fixation options include retrograde nailing or lateral plating. Nails are typically considered in arthroplasties that allow intercondylar access (“open box PS” or CR implants) and have sufficient length of the distal fragment to allow multiple locking screws to be used. This situation is rare, as most distal fragments are quite short. If a nail is chosen, use of a long nail is preferred, since it allows the additional fixation and alignment that diaphyseal fill affords. Short nails should be discouraged since they can “toggle” in the meta-diaphysis and do not engage the diaphysis to improve coronal alignment. Plates can be used with any implant type and any length of distal fragment. The challenge with either fixation strategy is obtaining stable fixation of the distal fragment while maintaining length, alignment, and rotation. Fixation opportunities in the distal fragment can be limited due to obstacles caused by femoral component lugs, boxes, stems, cement mantles, and areas of stress shielding or osteolysis. Modern lateral locked plates can be inserted in a biologically friendly submuscular extra-periosteal fashion. More recent developments with polyaxial locked screws (that allow angulation prior to end-point locking) may offer even more versatility when distal fragment fixation is challenging. The goal of fixation is to obtain as many long locked screws in the distal fragment as possible. High union rates have been reported with modern locked plating techniques, however, biplanar fluoroscopic vigilance is required to prevent malalignments, typically valgus, distraction, and distal fragment hyperextension

Peri-prosthetic fractures occurring in total shoulder arthroplasty represent surgical challenges both in decision making as well as surgical management. These fractures can involve both the humerus and scapula. In a few cases with minimal displacement conservative care may be employed. In most, however, surgical intervention is needed. Depending on the quality of the surrounding bone, the health of the patient, the stability of the existing implant, and the integrity of the surrounding soft tissues, options for management include open reduction and internal fixation, bone grafting, strut and cable fixation, or a combination of these techniques. In some cases revision arthroplasty is indicated. An approach to surgical decision-making, operative techniques and avoidance of complications will be discussed

As the incidence of total hip arthroplasty (THA) rises, an increasing prevalence of peri-prosthetic femur fractures has been reported. This is likely due to the growing population with arthroplasties, increasing patient survival and a more active life-style following arthroplasty. It is the 3rd most common reason for THA reoperation (9.5%) and 5th most common reason for revision (5% with fracture risk after primary THA reported at 0.4%-1.1% and after revision at 2.1%-4%). High quality radiographs are usually sufficient to classify the fracture and plan treatment. Important issues in treatment include stem fixation status and fracture location relative to the stem. Additional comorbidities will also influence treatment choices, of which the most critical is the presence of infection and the quality of bone stock. The most commonly studied, and reported classification system is the Vancouver. Type A are peri-trochanteric fractures with AL at the lesser and AG at the greater trochanter. B fractures are those around the stem with B1 fractures having a well-fixed stem, B2 a loose stem with adequate bone stock, and B3 representing loose stem and inadequate bone stock. C fractures are distal to the stem. Type A) Trochanteric Fractures: These are usually associated with lysis. Displaced fractures can be managed adequately with cerclage fixation and cancellous allograft to fill osteolytic defects. Undisplaced fractures usually heal well with symptomatic treatment. Type B) Fractures Around the Stem: The B1 type has a well-fixed component and is usually treated with extramedullary fixation plus graft. Contemporary plates have been designed specifically for these fractures. Strut allograft may be used to provide a more rigid construct. Spiral and long oblique fractures can be cerclaged while short oblique or transverse fractures require fixation anterior and lateral with cable plates and cortical strut grafts. Screws can be used distal to the implant, and cables used proximally. The B2 type has a loose prosthesis but otherwise good bone stock. In this setting, the fracture line may be extended on the lateral cortex of the femur as an extended osteotomy to provide easy access for cement removal. These fractures can be managed with an extensively coated stem if rotational stability can be obtained in the distal segment. If rotational stability over a 4 cm scratch interference fit of the stem isn't possible, then a fluted tapered modular stem should be used. Strut allografts improve initial stability. The B3 type has both a loose prosthesis and poor bone stock and in the younger patient restoration of bone stock should be a priority. Bulk femoral grafts may be needed. The elderly or low functional demand patient may be treated with a proximal femoral replacement. Because of soft-tissue deficiencies, a constrained acetabular liner may be needed to prevent instability. Type C) Fractures Distal to the Stem: These usually accompany a stable stem and many fixation devices are available. Locking plates have become most popular and should be secured with cerclage wires proximally around the component with screws distally. Retrograde nails may be employed if there is adequate bone distal to the stem tip and above the fracture

Displaced fractures of the neck of femur are routinely treated in the elderly by either cemented hemiarthoplasty, in the fit, or uncemented hemiarthroplasty, in the less fit. In Scotland the Scottish Intercollegiate Guidelines Network (SIGN) guidelines are followed to identify which patients should have a cemented prosthesis. This is based on cardiovascular status, and the age and fragility of the patient. An uncemeted prosthesis should be a final operation. A peri-prosthetic fracture is considered a failure of treatment as the patient then has to undergo an operation with a far greater surgical insult. We looked at all neck of femur fractures over a period of Jan 2007 to June 2010. The number of the peri-prosthetic fractures for uncemented hip hemiarthroplasties was established and a case note review carried out. There were 397 neck of femur fractures. 546 hemiarthroplasties were carried out, of which 183 were cemented, and 363 uncemented. 14 patients (4% of uncemented arthoplasties) had peri-prosthetic fractures. The case notes of these patients were analysed. There was a common link of significant cardiovascular risk, lack of falls assessment, and confusion. Cemented implants should be considered in those who have failed falls assessment, or are confused; even if the cardiovascular risk is significant. This decision should be made in conjunction with a senior anaethetist. This is being implemented in our unit and a prospective audit is being carried out over the same time period (July 2010 to Dec 2013) to assess the benefit

Displaced fractures of the neck of femur are routinely treated in the elderly by either cemented hemiarthoplasty, in the fit, or uncemented hemiarthroplasty, in the less fit. In Scotland the Scottish Intercollegiate Guidelines Network (SIGN) guidelines are followed to identify which patients should have a cemented prosthesis. This is based on cardiovascular status, and the age and fragility of the patient. An uncemented prosthesis should be a final operation. A peri-prosthetic fracture is considered a failure of treatment as the patient then has to undergo an operation with a far greater surgical insult. We looked at all neck of femur fractures over a period of Jan 2007 to June 2010. The number of the peri-prosthetic fractures for uncemented hip hemiarthroplasties was established and a case note review was carried out. There was 1397 neck of femur fractures. 546 hemiarthroplasties were carried out, of which 183 were cemented, and 363 uncemented. 14 patients (4% of uncemented hemiarthoplasties) had peri-prosthetic fractures. The case notes of these patients were analysed. We found there was a common link of significant cardiovascular risk, lack of falls assessment (only 14% of patients had a completed falls assessment and 35% sustained their fracture during an admission to hospital) and confusion (43% had a degree of dementia that caused significant confusion). Cemented implants should be considered in those who have failed falls assessment, or are confused; even if the cardiovascular risk is significant. This decision should be made in conjunction with a senior anaesthetist. This is being implemented in our unit and a prospective audit is being carried out over the same time period (July 2010 to Dec 2013) to assess the benefit

Peri-prosthetic joint infection (PJI) is one the most devastating complications of joint arthroplasty. Although PJI is an infrequent complication (the reported incidence is 1%-2% in the United States), it is the most common indication for revision total knee arthroplasty in the Medicare population and the third most frequent indication for revision total hip arthroplasty. Moreover, the prevalence of PJI appears to be on the rise, with a projected number exceeding 60,000 to 70,000 cases in the United States by 2020. It is estimated that more than 25% of revision procedures annually are attributed to PJI and this number is expected to increase in the upcoming years. The increase in the prevalence of obesity, diabetes, and other comorbidities among the patient population and the emergence of resistant infecting organisms are some of the reasons for the expected rise in the number of infections that medical community will witness. The challenges that PJI present to the orthopaedic community are on many fronts. Prevention of PJI has proven to be a difficult task indeed. Effective strategies for prevention of PJI are being refined. The Center for Disease Control will be publishing its updated Surgical Site Prevention Guidelines in the next few months that consists of specific recommendations for prevention of PJI. In recent years, strides are made in introducing novel molecular techniques for diagnosis of PJI, which may stand to change our practices. The current surgical technique for management of PJI, besides the immense cost, fall short of delivering high success to the patients. The major problem in eradication of infection relates to formation of biofilm on the implant surface and internalization of the organisms by affected cells. Biofilm is a sophisticated structure comprising of organisms embedded in multiple layers of glycoccalyx that allows the organisms to evade host immunity and is impenetrable to antibiotics. These organisms are capable of communicating through molecular mechanisms such as quorum sensing that affords them advantage for survival in the host environment. In recent years strategies to prevent colonization of the implant surface, an essential first step in formation of biofilm, or biofilm disruption techniques have been introduced. A recent International Consensus meeting on PJI that assembled more than 350 experts identified some of the best practices in this field and identified areas in need of future research. Moving into the future, the field of orthopaedics in general and PJI in particular stand to benefit from the discoveries in the field of molecular diagnostics, metabolomics and epigenetics

Vancouver B type peri-prosthetic hip fractures are increasingly common and represent a very complex and challenging problem in terms of management. Plate fixation has not always succeeded, and revision hip arthroplasty on a suboptimal trauma list can be a daunting prospect. Our technique is to use the opposite sided distal femoral LISS plate, inserted from proximally to distally in an inverted manner. Vastus lateralis is elevated off the trochanteric ridge, and a small amount of bone is removed from the ridge to get the plate to sit snugly. The fracture is opened only enough to achieve reduction, and fixation with locking screws are placed percutaneously distal to the fracture. Bone grafting or cable fixation can also be applied at the fracture site. 20 consecutive patients with Vancouver B peri-prosthetic hip fractures were reviewed. The average patient age was 78 yrs. 14 fractures occurred in cemented and 6 in uncemented femoral stems. 12 fractures occurred in primary THR and 8 in bipolar hip hemiarthroplasty. Six were managed using the inverted LISS plate, 6 using other methods of fixation, and 8 with revision THR. In terms of mortality at 12 months, there was no difference between the treatment arms, with 1 death in the LISS and other fixation group respectively and 0 deaths in the revision THR group. From a morbidity perspective there was no difference with respect to post-op medical complications, weight bearing status and length of hospital stay. There was, however, a difference between the inverted LISS plate group and other fixation methods group compared with the revision THR group in terms of average transfusion requirement (2 units and 3 units vs 8 units) and average operative time (80 mins and 100 mins vs 465 mins). 1 LISS plate failed in the 12 month period, with 1 Revision THR and 2 from the other fixation group. This study suggests that it is a stable method of fixation, particularly in the type B1 and B2 subtypes. It may also be used in patients with multiple co-morbidities who cannot undergo a revision procedure and in patients who are minimally/non ambulant. In one patient, we used it to stabilize the fracture before progressing to a later, more controlled, revision hip replacement situation. LISS fixation has a short operative time, low transfusion requirement, low failure rate and is technically easier to perform than revision surgery

Introduction: Peri-prosthetic fractures following hip resurfacing arthroplasty are difficult fractures to treat. The surgeon is faced with the task of either attempting to fix the fracture if feasible or revise the resurfacing implant to a conventional total hip replacement. Method & Results: Here we report of a novel way of fixing a peri-prosthetic fracture following resurfacing hip arthroplasty using Polyaxial locking plate fixation. A 53 year old man sustained a intertrochanteric fracture below his resurfacing metal on metal hip prosthesis following a fall. He had his hip resurfaced 3 years back for osteoarthritis in another hospital. He underwent surgery to fix the fracture using a polyaxial locking plate with no post-operative complications. He was mobilised non-weight bearing for the initial six weeks and weight bearing as tolerated thereafter. He went on to union and was moblising without any problems in three months time. His follow-up x-rays at 8 months showed fracture healed with no evidence of prosthesis problems. Discussion: There are various methods of treating a periprosthetic fracture of a well fixed resurfaced hip implant. The two types of management are open reduction and internal fixation and revision to a stemmed hip implant. These fractures can be fixed with cannulated hip screws, blade plate device or plating with screws avoiding the stem of the resurfacing prosthesis. We used the polyaxial locking plate device with good result thereby avoiding the need for revision surgery with its attendant risks. Using this implant is a useful alternative for these fracture patterns

Periprosthetic fractures in total hip arthroplasty lead to considerable morbidity in terms of loss of component fixation, loss of bone and subsequent functional deficits. We face an epidemic of periprosthetic fractures as the number of cementless implants inserted continues to rise and as the number of revisions continues to increase. The management of periprosthetic fractures requires careful preoperative imaging, planning and templating, the availability of the necessary expertise and equipment, and knowledge of the potential pitfalls so that these can be avoided both intra-operatively and in follow-up. There is a danger that these cases fall between the expertise of the trauma surgeon and that of the revision arthroplasty surgeon. The past decade has afforded us clear treatment algorithms based on fracture location, component fixation and the available bone stock. We still nevertheless face the enduring challenge of an elderly population with a high level of comorbidity who struggle to rehabilitate after such injuries. Perioperative optimisation is critical as we have seen prolonged hospital stays, high rates of systemic complications and a significant short term mortality in this cohort. We have also been presented with new difficult fracture patterns around anatomic cementless stems and in relation to tapered cemented and cementless stems. In many cases, fixation techniques are biomechanically and biologically doomed to fail and intramedullary stability, achieved through complex revision is required. The treatment of unstable peri-prosthetic femur fractures can be technically challenging due to the weak non-supportive bone stock. We have seen an increase in the frequency of Type B3 fractures that require complex reconstruction with modular tapers, interlocking implants and proximal femoral replacements. Our reconstructive practice has evolved; the aims of femoral reconstruction include rotational and axial stability of the stem, near normal hip biomechanics and preserving as much femoral bone as possible. The advent of modular prostheses that gain distal fixation but have proximal options has extended the scope of this type of fixation. We now favor modular tapered stems that afford us the opportunity to reconstruct such femora whilst attempting to preserve the proximal bone. In effect, distal cone or taper fixation provides the initial stability required for the procedure to be successful but the proximal modular implant subsequently load shares to decrease stress shielding, distribute stress more evenly through the femur and minimise the risk of stem fracture. Such systems provide the intraoperative versatility that these cases require. The use of interlocking stems with coated ingrowth surfaces offers a relatively appealing solution for some complex fractures and avoids the complications that would be associated with unstable fixation or resection of the proximal femur. Periprosthetic acetabular fractures are also increasingly recognised. This is in part due to the popularity of press fit components, which increase fracture risk both at the time of insertion and later due to medial wall stress shielding and pelvic osteolysis, and partly due to the increasing frequency of severe defects encountered at the time of revision surgery. These can present a very difficult reconstructive challenge and may require porous metal, cup-cage or custom reconstruction. Periprosthetic fractures continue to cause problems worldwide. The sequelae of periprosthetic fractures include the financial cost of fixation or revision surgery, the associated morbidity and mortality in an elderly frail population, the difficulty with mobilisation if the patient cannot fully weight bear and a poor functional outcome in a proportion of cases. The battle over which patients or fractures require fixation and which require revision surgery continues

Peri-prosthetic fractures above a TKA are becoming increasingly more common, and typically occur at the junction of the anterior flange of the femoral component and the osteopenic metaphyseal distal femur. In the vast majority of cases the TKA is well fixed and has been functioning well prior to fracture. For loose components, revision is typically indicated. Often, distal femoral mega prostheses are required to deal with metaphyseal bone loss. Good results have been reported in small series, however, complications, including infection remain concerning, and these implants are incredibly expensive. Although performing a mega prosthesis in the setting of a well fixed TKA is not unreasonable due to immediate full weight bearing, in my opinion, prosthetic replacement should be limited to cases of failed ORIF (rare), or in cases where fixation is likely to fail (i.e., severe osteolysis distally). For the majority of fractures above well fixed components, internal fixation is preferred for the main reason that the overwhelming majority of these fractures will heal. Fixation options include retrograde nailing or lateral locked plating. Nails are typically considered in arthroplasties that allow intercondylar access (“open box PS” or CR implants) and have sufficient length of the distal fragment to allow multiple locking screws to be used. This situation is rare, as most distal fragments are quite short. If a nail is chosen, use of a long nail is preferred, since it allows the additional fixation and alignment that diaphyseal fill affords. Short nails should be discouraged since they can “toggle” in the meta-diaphysis and do not engage the diaphysis to improve coronal alignment. Plates can be used with any implant type and any length of distal fragment. The challenge with either fixation strategy is obtaining stable fixation of the distal fragment while maintaining length, alignment, and rotation. Fixation opportunities in the distal fragment can be limited due to obstacles caused by femoral component lugs, boxes, stems, cement mantles, and areas of stress shielding or osteolysis. Modern lateral locked plates can be inserted in a biologically friendly submuscular extra-periosteal fashion. More recent developments with polyaxial locked screws (that allow angulation prior to end-point locking) may offer even more versatility when distal fragment fixation is challenging. The goal of fixation is to obtain as many long locked screws in the distal fragment as possible. High union rates have been reported with modern locked plating techniques, however, biplanar fluoroscopic vigilance is required to prevent malalignments, typically valgus, distraction, and distal fragment hyperextension