Unified Classification System (UCS)

for peri-prosthetic fractures (PPFx)

Waleed A Abdulwahid 6th Emirates International Orthopedic Congress

Consultant surgeon Dubai, UAE
Medical City, Iraq May 3-5, 2018
Learning outcome

• Outline the importance of PPFx

• Explain the rationale behind UCS classification

• Discuss reliability & validity

Introduction

• An increasingly
common
complication of
TJA.

• Third Most
Common Cause of
Revision.
Incidence Increasing • Increasing patient longevity
• more demanding activity
• 1987-2003
– 0.14%

• 2004-2007
– 0.78%

• 2008-2015
– 1.1%
Summary of the Published
Incidence/Prevalence of
Periprosthetic Fractures
Associated With Total Hip
Arthroplasty (THA)

Musculoskeletal Key
Periprosthetic Fracture,
Prevention/Diagnosis/Treatment
Christopher R. Gooding, Donald S.
Garbuz, Bassam A. Masri and Clive P.
Duncan
Etiology

• Trauma
– Usually trivial incident
– Low energy type
• Osteoporosis
• Stress Risers in bone
Risk Factors

• Stress risers
– Previously bone window
– Prior perforations/screw
holes
– Congenital bowing
– Prior osteotomy or
fractures
• Osteolysis
• Loose implant
It happens in Osteoporotic bone

• Fragile soft tissue

• Fragile bone
• Fragile patient
• No place for fragile surgery
Outcome of PPFx

• High risk of complications

– 14 (31%) complication
– 6 NU, 6 infection, 2 Loosening Beaule et al. 2014

• High rate of NonUnion. Hoffman et al 2016

• High Mortality rate: 11% / 1st year Bhattacharyya - 2007

Case

• 88 y old F
• Femoral neck fracture
2 days later
2.5 months later
Difficult to manage …. Poor Outcome

• Careful evaluation of the patient

1. Comorbidities
2. Activity level

• Careful evaluation of the fracture itself

1. Classification
2. Algorithmic management
 Unified Classification System (UCS)
Duncan, Haddad

The UCS is alphabetical in its core design for ease of application

Core principles
1. The location of the fracture

2. The fixation of the component

3. The adequacy of the bone stock and bone strength supporting the
implant
Voncouver classification

Duncan CP, Masri BA Fractures of the Femur after hip replacement. Instr Course Lec. 1995; 44:293-304.
.
Location: For the identification of the bones,
the numbering follows that of the
Joints/Bones AO/OTA Fracture and Dislocation

▪ I: Shoulder ◼ 1:Humerus
▪ II: Elbow ◼ 2: Forearm
▪ III: Wrist ◼ 3: Femur
▪ IV: Hip ◼ 4: Leg
▪ V: Knee ◼ 6: Pelvis
▪ VI : Ankle ◼ 7: Hand
◼ 8: Talus
Types

A: Apophyseal
B: Bed of Implant
C: Clear of implant
D: Dividing the bone between two implant
E: Each of two bone supporting one arthroplasty
F: Facing and articulating with hemiarthoplasty

For simplicity , Type, Bone, Joint

Type A of the patella associated with knee replacement

Type B2 of the femur associated with hip replacement
Bone Quality, Fixation

Good bone Good bone Poor bone

No loosening Loosening Loosening
Type A - apophyseaI or extraarticular/perlarticular

Adjacent to implant, little effect on stability

This category would include such examples as:

• The tuberosities of the humerus
• The humeral epicondyles or olecranon tip at the elbow
• The trochanters and epicondyles of the femur
• The spinous extraarticular pelvic fractures
• The poles or tips of the patella
• The tibial tuberosity as well as the malleoli.

The need for surgical management would be based on the

location and characteristics of each fracture type
Type B-bed of the implant or around the implant

• Bl Good bone, no implant loosening

• B2 Good bone With implant loosening
• B3 Poor bone or bone defect with implant loosening

Distinction between B2 and B3 is one of individual

interpretation, without a clear-cut transition
Type c-clear of or distant to the Implant

• quite distant to the arthroplasty

• the modern principles of fracture

management apply, with little influence
brought to bear by the preexisting joint
replacement.

• some type of modified fixation may have to be

taken into consideration, (cerclage wires,
cables, or mono-cortical screws).
Type D - dividing the bone between two implants.
interprosthetic or intercalary

• Quite uncommon as the fracture involves a long bone that

supports two prostheses, both proximal and distal to the
fracture site

• Aapproaching type D fractures by separate analyses of

implant stability as well as the available bone stock around
each of the implants.

• Treatment should be based upon those separate analyses.

Appropriate treatment may involve revision of one, both, or
neither arthroplasty.
Combinations of Fractures
Separate analyses

Type D interprosthetic or intercalary fracture, together with the

• Type B3 periprosthetic fracture with severely compromised bone stock
• Type E polyperiprosthetic fractures

Represent the three most challenging groups of fractures.

Type E

• Type E fracture involving both sides of a joint replacement, ex. with a

periprosthetic fracture of the acetabulum and femur.

• Separate analyses reveal a type B3 fracture of the acetabulum and

B2 fracture of the femur.
Type F-facing and articulating with - hemiarthroplasty

the principles of management ….. will depend on the

• Degree of fracture displacement

• Health of the articulation, ie, whether it was degenerated prior to the most
recent injury.
Reliability & Validity of UCS

• The goal of any classification system is ultimately to improve patient

outcome.
• To be able to accomplish this goal, “guide treatment”
• the classification must …….....……… be reliable, and valid
Reliability & Validity of UCS

Field testing the Unified Classification System for periprosthetic

fractures of the femur, tibia and patella in association with knee
replacement: An international collaboration.
M Van der Merwe, J & S Haddad, F & P Duncan, C. Bone & Joint
Journal, 96-B(12):1669-73 · December 2014

The UCS has substantial inter-observer reliability & “near

perfect” intra-observer reliability when used for PPFx
associated with knee replacement in the hands of experienced &
inexperienced
Reliability & Validity of UCS
The reliability and validity of the Unified Classification System
of periprosthetic femoral fractures after hip arthroplasty
JF Huang et al. Acta Orthop. Belg., 2016, 82, 233-239

• the UCS for periprosthetic femoral fracture is reliable.

• Intraobserver and interobserver agreement was judged to be substantial

to almost perfect.

• the validity assessment for type B fracture subgroups showed a

substantial agreement. But failed to achieve perfect agreement
Implant fracture
1. Alone : revision
2. Bone fracture : revision + fixation/reconstruction
51 ys male
Acute pain . bedridden

AG ?
B1 ?
Stability
Bone stock
Question

• Revision with ETO

• B1 …… B2 ?
1 year
Take home

A reliable & valid classification system helps to:

• better understand the problem,
• construct a treatment algorithm,
• Maximize the chances of success.

Preoperative planning is essential, but ….. !!

• must have the flexibility to change the plan should
circumstances change during the course of surgery.