The treatment of periprosthetic hip fractures in stable cemented prostheses requires individualized planning, mastery of re-approach surgery in a fibrotic field, and the technical ability to perform secure hybrid fixation without implant revision.

This training presents the complete management of a periprosthetic hip fracture with a stable cemented prosthesis using a posterolateral approach associated with osteosynthesis using a trochanteric plate, application of perifemoral cables, and cortical screws, including strategies for proximal anchorage, torque control in osteoporotic bone, and immediate postoperative full weight-bearing, demonstrated in detail from a surgical perspective.

TRAINING FOCUS

• Posterolateral approach and anatomical landmarks in re-approach surgery.
• Surgical planning for periprosthetic hip fractures.
• Assessment of prosthetic stability and decision-making for fixation without revision.
• Anatomical exposure in a fibrotic field and identification of tissue planes.
• Proximal plate anchorage through transtendinous portals.
• Perifemoral cable passage technique and cable passer selection.
• Cable torque control in osteoporotic bone.
• Fixation with a cortical screw in an oval hole while avoiding the prosthesis.
• Stabilization of the femoral calcar with a cable proximal to the lesser trochanter.
• Fluoroscopic control and assessment of implant positioning.
• Percutaneous fixation of the distal screw with minimally extended exposure.
• Full weight-bearing release and immediate rehabilitation protocol.

DETAILED CONTENT

• Structured Surgical Planning: Definition of the operative strategy based on preoperative fluoroscopic images, assessment of cemented component stability, and planning of the fixation sequence without prosthetic revision.
• Re-approach Through the Posterolateral Approach: Technique for re-identification of anatomical planes in a fibrotic field using the posterior superior iliac spine as a continuous reference, with the limb positioned at 45° of flexion for safe diaphyseal alignment.
• Anatomical Exposure in a Fibrotic Field: Strategies for dissection in anatomy altered by previous surgery, including identification of the iliotibial tract, fascia lata, and residual sutures of the external rotators, preserving muscular and vascular structures.
• Proximal Anchorage Through Transtendinous Portals: Creation of portals in the gluteus medius and gluteus minimus tendons to position the proximal end of the trochanteric plate directly against the bone, preventing soft-tissue interposition.
• Selection and Passage of Perifemoral Cables: Practical criteria for choosing the cable passer curvature radius according to the diameter of the femoral diaphysis, minimizing muscle trauma and ensuring a bone-hugging trajectory for effective tensioning.
• Torque Control in Osteoporotic Bone: Progressive tactile approach to cable tensioning in bone with low mineral density, preventing cortical fracture due to overload while ensuring firm fixation under continuous fluoroscopic control.
• Fixation with a Screw in an Oval Hole: Use of a directional cortical screw in the plate’s oval hole to precisely bypass the cemented femoral component, adding significant stability to the final construct.
• Stabilization of the Femoral Calcar: Placement of a cable proximal to the lesser trochanter for fixation of the femoral calcar, with an alternative strategy through the superior region of the plate when direct access to the intended level is anatomically limited.
• Percutaneous Fixation of the Distal Screw: Placement of the distal screw with minimal extension of the exposure, using digital palpation as a guide for precise positioning and reduction of additional surgical trauma.
• Fluoroscopic Assessment and Final Result: Intraoperative confirmation of ideal implant positioning with three cables superior to the fracture, a trochanteric screw, and hook anchorage, validating mechanical stability for immediate full weight-bearing.

INCLUDED MATERIAL

Detailed PDF: The PDF provides a complete analysis of the periprosthetic hip fracture, classification criteria and decision-making for fixation without prosthetic revision, sequence of operative steps, biomechanical principles of hybrid fixation with a trochanteric plate, cables, and screws, re-approach strategies in a fibrotic field, torque control in osteoporotic bone, and a rehabilitation protocol with immediate postoperative full weight-bearing.