Introduction                       

Total hip replacement is extremely effective in relieving pain and restoring function in the diseased hip and is the second most common elective surgical procedure performed in the UK. The wider acceptance of total hip replacement and an increase in the use of uncemented components along with a rise in aging population, has led to increase in the rates of revision hip arthroplasty and the frequency of occurrence of periprosthetic fractures. It is important that the modern reconstructive hip surgeon be familiar with the classification and treatment of these fractures.

On the acetabular side, fractures can occur during surgery because of the impaction forces,1 or after surgery due to bone loss in a failed arthroplasty.2 It is important to diagnose and treat these fractures early to avoid a catastrophic outcome.

Femoral fractures may also occur during or after surgery. Failure to recognize intraoperative fracture may lead to poor outcome due to nonunion and malunion or implant loosening. Postoperative fractures can be difficult to treat with high risk of complications and unsatisfactory outcomes. The Vancouver classification3 of periprosthetic femoral fractures is a simple and validated system4 that enables the surgeon to decide the most appropriate treatment based on three factors—the location of the fracture, the stability of the femoral stem and the quality of the remaining bone stock. The authors have modified the classification to cover the intraoperative fractures as well.

 

Acetabulum                       

INTRAOPERATIVE FRACTURES

 

Epidemiology and Etiology

Intraoperative periprosthetic fractures of the acetabulum are less common than femoral fractures. They are reportedly more common in association with uncemented cups.5-9 McElfresh and Coventry10 reported only one intraoperative periprosthetic acetabular fracture during 5400 cemented total hip arthroplasties (a prevalence of <0.02%). Sharkey et al1 reported thirteen intraoperative acetabular fractures that occurred during the insertion of uncemented components; nine were diagnosed intraoperatively. Haidukewych et al11 reviewed a series of 7121 primary total hip arthroplasties and reported an intraoperative acetabular fracture during 21 (0.4%) of 5359 uncemented acetabular components. No acetabular fractures occurred during any of the 1762 procedures done with a cemented component. Seventeen of the fractures were stable and four were treated with supplemental

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screw fixation. Elliptical monoblock cups had the highest risk of fracture, with a prevalence of 3.5% (twelve) of 339 compared to prevalence of 0.09% (two of 2198) with hemispherical modular shells.

Total Hip Arthroplasty

 

Intraoperative acetabular fractures occur most frequently during insertion of the component.10 This is due to the under reaming required for achieving press fit fixation of a cementless acetabular component when no screws are used. In order to minimize the risk of fracture, it has been suggested that components not be oversized by >2 mm.10 Despite some authors asserting that oversizing by as much as 4 mm9 does not result in acetabular fracture, it is generally accepted that components should be oversized by no more than 2 mm.12 Factors contributing to the risk of these fractures include osteopenia, metabolic bone disease, osteolysis, aggressive reaming and use of an elliptical cup.13

 

Classification

Callaghan14 described the pattern of acetabular fractures observed during the insertion of an oversized acetabular component on the basis of an in vitro study. He described anterior wall, transverse, inferior lip, and posterior wall fractures according to anatomical location.

Della Valle et al15 proposed a classification system of acetabular fractures that is quite exhaustive. Type–I fractures occur at the time of insertion of the acetabular component and are subclassified as type A if they are diagnosed intraoperatively, are undisplaced and associated with a stable implant. Type B fractures are diagnosed intraoperatively and are displaced and type C when the fracture is diagnosed postoperatively. Type–II fractures occur at the time of component removal and are type A if there is < 50% loss of bone stock and type B if there is > 50% loss of bone stock. Type–III deal with postoperative fractures. The Vancouver Group13 proposed the following classification of intraoperative acetabular fractures: Type I—an undisplaced fracture that does not compromise the stability of the component; Type II—an undisplaced fracture that potentially compromises the stability of the reconstruction, such as a transverse fracture of the acetabulum (with pelvic discontinuity or dissociation) or an oblique fracture that separates the anterior column and dome from the posterior column (a much less common injury); and Type III—a displaced fracture. If there is substantial displacement, fixation of the cup will be compromised unless the fracture is somehow stabilized.

 

Diagnosis

A high index of suspicion for intraoperative acetabular fractures is required as they can be difficult to identify. A full clinical and radiographic assessment of the affected area is required. This should include intraoperative stress testing of the pelvis and the acetabular component to determine the stability of the component, and it may require removal of the cup to fully examine the acetabulum.13

 

Treatment and Results

The principles of management of periprosthetic fractures include fracture stabilization, prevent propagation of the fracture, maintain stability and alignment of the component, and achieve fracture union.16,17

Treatment of intraoperative acetabular fractures is determined by fracture severity.1 If the fracture is a minor crack and the implant is stable, the surgeon may elect to leave the fracture alone or to augment cup fixation with screws. For intraoperative acetabular fractures that render the pelvis unstable, the surgeon should stabilize the pelvis, with a plate if necessary, and gain stable cup fixation, either with an uncemented hemispherical cup or with an antiprotrusio cage. An all-polyethylene cup can then be cemented into the reconstruction cage. This is the so-called cup-cage-construct technique.18 Early results using this technique in revision surgery have been good but there are no reports of use of this technique for intraoperative fracture.

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POSTOPERATIVE FRACTURES

 

Epidemiology and Etiology

Periprosthetic Fractures After Total Hip Arthroplasty

 

The first description of periprosthetic acetabular fractures was by Miller19 in 1972. Postoperative acetabular fractures are infrequent and usually involve significant trauma or stress fracture through an area of marked bone loss or osteolysis. Stress fracture should be considered in an elderly woman with a relatively acute onset of symptoms after an increase in activity level20 and may result in pelvic discontinuity. Berry et al2 described the diagnostic features of pelvic discontinuity which include any visible fractures on the AP radiographs, with rotation or translation of the inferior portion of the pelvis relative to the superior part. In some cases, however, it is difficult to appreciate a fracture line because of obscuring hardware or metallic implants. Judet views or CT scan may be helpful.

 

Classification

Peterson and Lewallen5 classified these fractures into Type-I with a radiologically and clinically stable acetabular component and Type-II unstable component.

 

Treatment

Early postoperative fractures can be treated according to their pattern. Patients with stable, minimally displaced acetabular fractures, where a cementless component has been augmented with screw fixation can be treated conservatively with union being expected in most cases. Nondisplaced fractures with radiographically stable components are treated with 12 weeks of touchdown weight bearing. Displaced fractures with component loosening require revision with wall or column fixation, bone grafting and revision cementless acetabular placement.

Late presenting fractures often occur around cemented acetabular components, usually in the presence of significant osteolysis. These fractures typically are minimally displaced and initial conservative treatment has been proposed to allow union and avoid unnecessary stripping of the posterior column at eventual revision.14 Peterson and Lewallen5 reported on eleven late periprosthetic acetabular fractures (nine cemented cups). Eight of eleven fractures were stable, and two fractures were unstable. One patient died of intrapelvic bleeding from associated vascular injury at the time of his trauma. Patients with unstable acetabulae were treated with revision and plate or cage, and patients with stable implants were treated conservatively with modified activities. Of the ten surviving patients followed, eight of the patients (including four patients with stable implants that went on to union) went on to revision because of persistent pain. The investigators concluded that these fractures had a poor prognosis and may need further reconstruction, but union can be achieved and salvage revision can be successful.

The Mayo Clinic series reported on periacetabular fractures that resulted in pelvic discontinuity at revision surgery.2 Treatment was with antiprotrusio cages, uncemented components, or cemented components without cages. Seventy-seven percent of patients who had cages had a satisfactory outcome, 56% of patients who had uncemented components had a satisfactory outcome, and none of the patients with cemented cups alone had satisfactory result.

 

Femur                         

INTRAOPERATIVE FRACTURES

 

Epidemiology

Intraoperative fractures that are detected at the time of surgery have been reported in primary uncemented femoral implantations from 1 to 3%23 and up to as high as 5.4%.22 Comparatively,

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the incidence is low at 0.3 to 1.2% when the femoral component is inserted with cement.22 In revision setting, the incidence was higher in uncemented femoral implantation (21%) than when the femoral component was cemented (3.6%)22. Additionally, revision THA with impaction grafting is associated with a higher incidence of intraoperative and postoperative fractures.

 

Total Hip Arthroplasty

 

Classification

Intraoperative femoral fractures include many types and extent of fracture. Some fractures are recognized intraoperatively, whilst others are detected postoperatively as a fracture line or displacement on X-ray.23,24 Implant survival depends upon fracture pattern and implant stability.

Classifications by location, displacement, and implant stability have been reported. All classifications label location proximal to distal and complexity increases as fractures move distal. Most classification systems subclassify “A” as nondisplaced and “B” as displaced fractures.

Mallory et al25 described Type 1 fractures in the proximal femur, Type 2 around the

stem, and Type 3 at or below the tip of the prosthesis. Johansson et al24 classified fractures into: Type 1 fracture was proximal to the prosthesis tip; Type 2 at the region of the tip of the prosthesis; and Type 3 below the prosthesis. Stuchin26 described a Type 1 fracture as proximal, Type 2 as long spiral fractures near the tip, Type 3 propagating from stress points in the femur, and Type 4 as unclassified.

Although all femoral classification systems generally grade on location and displacement for description of fractures, the Vancouver system has been the most accepted3. Modified to accommodate intraoperative fractures, the Vancouver system describes fractures in the same proximal-to-distal fashion with attention to configuration and stability of the fracture. Type A fractures are in the proximal femoral metaphysis and do not extend into the diaphysis, Type B fractures are diaphyseal but do not extend into distal diaphysis, and Type C fractures extend distal and beyond long-stem fixation length. Each of these groups is further subdivided into subtypes 1, 2, and 3. Type 1 includes cortical perforations, Type 2 represents undisplaced linear fractures, and Type 3 includes displaced and unstable fractures.

 

Results

Results have not been universally good with intraoperative fracture. Johansson24 reviewed 23 femoral fractures—6 proximal to the tip of the prosthesis, 15 fractures at the distal tip of the prosthesis, and 2 distal to the prosthesis. Some of the proximal fractures were treated with operative procedures, and some with nonoperative intervention. Of the six proximal fractures, two had satisfactory results—both treated operatively with fixation or long stem. All 15 fractures at the distal tip were treated with operative intervention. Eight of the fifteen had satisfactory results. The remaining seven failed due to malunion, loosening, or heterotopic ossification. Both fractures distal to the tip had unsatisfactory results secondary to refracture or loosening. Taylor27 reviewed 11 intraoperative fractures, most of which were in the proximal femur. The final outcome was not compromised, but morbidity and extended convalescence were noted.

Others have reported more favorable outcomes. Fitzgerald et al28 reported on 40 fractures in 630 cementless femurs (6.3%). Thirty-nine were treated satisfactorily with Parham bands or wires and graft. One patient had a fracture beyond the distal tip that was diagnosed postoperatively and treated successfully with cast immobilization. All patients remained on protected weightbearing for 2 to 4 months. Mallory et al25 reported on 56 intraoperative fractures during cementless arthroplasty. Of these, union occurred in 45 proximal fractures and 9 Type B fractures without any adverse effect compared with a cohort of patients with THA who did not have a fracture.

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Revision surgery is often associated with poor bone quality and potential deformity. Intraoperative fracture is more common and difficult to treat in these situations. Paprosky et al29 reported on 15 fractures in 170 revisions (8.8%) with an additional 10 cortical perforations during cement or component removal. No complicating events from fracture were noted in that series. Christensen et al30 described 10 intraoperative fractures during 159 revision procedures (6.3%) who were treated with open reduction and internal fixation. Although all fractures united only six of ten patients regained satisfactory function.

Proximal osteotomy or trochanteric slide helps to minimize distal fractures.31 These osteotomies led to higher incidence of proximal fractures at the osteotomy. Chen et al31 reported successful healing of these proximal fractures using cerclage wires with or without cortical strut allograft, without compromising the outcome of the revision procedure.

 

Treatment

Summary recommendations can be guided according to the Vancouver-adapted classi-fication16 (Flow chart 37.1).

Type A1 fractures denote simple proximal perforations and may be treated with simple local bone graft, and Type A2 fractures describe proximal linear cracks, which are amenable to cerclage wire fixation. Type A3 fractures reflect unstable fractures of the calcar femorale and/or trochanter. Diaphyseal fitting stems with cable and/or trochanteric clamps may be needed to achieve a stable construct.

Type B1 fractures include diaphyseal cortical perforations that most commonly occur from cement removal devices or reamers during canal preparation. Strut graft with cerclage

 

Periprosthetic Fractures After Total Hip Arthroplasty

 

Flow chart 37.1: Treatment algorithm for periprosthetic femoral fractures, when they are recognized intraoperatively

 

 

 

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Total Hip Arthroplasty

 

Flow chart 37.2: Treatment algorithm for periprosthetic femoral fractures, when they are recognized in postoperative period

 

 

 

 

wire is recommended. If recognized, the perforation should be bypassed by two cortical diameters using a longer stem. Type B2 fractures denote diaphyseal undisplaced linear cracks. These are often diagnosed on postoperative X-ray and may be treated with 6-12 weeks of limited weightbearing or cerclage wire with or without a strut allograft to bypass these fractures. Type B3 fractures indicate displaced diaphyseal fractures. Displaced fractures of the femoral shaft often occur through an area of weak bone at the time of dislocation of the hip. They also can occur at the time of femoral cement removal or with broach or implant insertion. Complexity of care is more pronounced with Type B3 fracture types. Fracture reduction with cerclage wires, cable, and strut graft with well-fitted long stems is indicated. Type C1 fractures denote distal perforations during cement removal or canal preparation.

These fractures are best treated with strut and cerclage. Type C2 fractures extend linear cracks almost to the knee. These fractures are best treated with cerclage and onlay strut graft. Displaced Type C3 fractures require open reduction and internal fixation (ORIF) of the distal femur. Cable plate, locking plate, or retrograde nail with strut grafting are possible treatment options.

 

INTRAOPERATIVE FRACTURES DETECTED POSTOPERATIVELY

Occasionally, intraoperative fractures are diagnosed in the immediate postoperative period. Full radiographic assessment is necessary. Late-recognized femoral fractures are usually undisplaced and stable. Patients may be treated nonoperatively with protected weightbearing until fracture union. Displaced fractures with femoral component instability are addressed with revision and ORIF as described in late postoperative fractures (Flow chart 37.2).

 

POSTOPERATIVE FRACTURES

The prevalence of postoperative fracture ranges from 1% in primary femoral components to 4% in revision femoral components.2 Postoperative fractures are often caused by minor trauma. Adolphson et al32 described 80% of fractures caused by minor trauma, whereas in Beals and Tower33 series 84% of fractures were associated with minor trauma. Major trauma was the etiology in 8.5% of reported cases.34

 

Classification

Late postoperative femoral fractures are more common than acetabular fractures in hip arthroplasty. Generally, classifications of femoral fractures have been guided by location of the fracture with attention to implant stability. Many investigators including Morrey and

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Periprosthetic Fractures After Total Hip Arthroplasty

 

Kavanagh,35 Whittaker et al,36 and Mont and Maar37 have introduced classifications for periprosthetic fracture. All investigators have used a combination of prosthetic stability and location as identifiers for the fracture. The Vancouver classification,3 which is now accepted for detailing femoral periprosthetic fractures, addresses the three most important factors: location, stability of the implant, and bone quality. In the Vancouver classification, the femur is divided into three locations: A, B, and C.

Type A fractures are confined to the trochanteric region. They are subdivided into Type A-G fractures of the greater trochanter and Type A-L fractures of the lesser trochanter. Type B fractures involve those that occur around or immediately below the prosthesis. Type B1 fractures designate fractures of the level of the prosthesis where the prosthesis is solidly fixed. Type B2 fractures are located at the prosthesis but with a loose prosthesis. Both B1 and B2 fractures also imply reasonable bone quality. Type B3 fractures occur at the level of the prosthesis but where compromised or osteopenic/osteolytic or comminuted bone is involved with the fracture. These implants are considered loose with poor bone quality. Type C fractures occur farther below the femoral component. These fractures include those distant to the femoral component, potentially even as far as the supracondylar or intercondylar area.

 

Results—General Principles

Nonoperative treatment is now indicated in undisplaced Type A fractures. Protected weightbearing, traction, and casts34 have been used. Johansson et al24 described 37 fractures in 35 patients. Ten of the 37 were treated nonoperatively using a combination of traction, traction with early mobilization and spica casting. Twenty-five of the fractures were treated operatively with plates and screws with or without long stem femoral component placement. These authors reported best results with the use of long stem prosthesis and fixation. The only satisfactory results seen in nonoperative treatment involved very proximal fractures with maintained prosthesis integrity. The best results were in patients revised to long-stem prostheses.33 Somers et al25 reported on 34 fractures treated nonoperatively. Thirty-three of the 34 healed but with prolonged treatment and high complication rates.

Surgical intervention is more frequently recommended than nonoperative treatment in the care of periprosthetic postoperative fracture. A surgeon must be familiar with extensile femoral surgical approaches. Intraoperative cultures and antibiotics are recommended. Lateral exposure of the femur is combined with a modified lateral or posterior hip approach. When exposed, removal of debris and accentuating displacement for purposes of debridement may aid in later reduction. Generally, techniques for ORIF are used in the presence of well-fixed components. This can be accomplished with plate/wire and strut graft combinations. Plates may be used exclusively or with strut graft augmentation.40 Another alternative is two strut grafts at 90°. Cable plate systems such as the Dall-Miles29 (Stryker Orthopaedics, Mahwah, NJ) or the Ogden plate41 (Stryker Orthopaedics) can be used effectively to stabilize fractures with implants. Venu et al42 described 12 periprosthetic fractures treated with a Dall-Miles plate and cortical strut graft. Nine of the 12 united with three requiring further surgery for nonunion. Tadross et al43 reported seven fractures treated with Dall-Miles; three of the fractures healed and four failed. Failures were believed secondary to varus stem placement with altered biomechanics. Recommendations for additional allograft strut were noted. Chandler44 reported on 21 of 22 patients with fractures uniting when a metal plate on one cortex was combined with strut graft on the other cortex.

Revision for femoral periprosthetic fracture is necessary in loose or unstable components. Results for revision have reflected the challenges of this fixation. Beals and Tower33 reviewed 102 interventions in 93 periprosthetic fractures by different surgeons. Results were excellent in 32% and poor in 52%. Although high complication rates were seen in all groups, cementless revision components faired better than cemented components. The best results were seen in patients treated with long-stem cementless implants. Lawrence et al45 and

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Total Hip Arthroplasty

 

Paprosky and Aribindi46 have used extensively porous-coated implants to bypass fractures. Springer et al47 reported best results with Type B femoral fractures using an uncemented extensively coated long-stem prosthesis. Mont and Maar,48 in their review of 487 patients from 26 reports, reported that open reduction with cerclage plates or revision to long-stem cementless components was better than screw fixation or traction. Wagner-style prostheses have also been successful in geriatric patients.49 Ko et al49 reviewed 14 patients over 3 to 5 years. All prostheses appeared radiographically stable. Seven patients had excellent outcomes, and three patients had good outcomes.

Severe bone loss proximally with periprosthetic fractures can be treated with segmental allograft or proximal femoral replacement. Wong and Gross50 reported on 19 patients treated with proximal femoral allograft. Of the 15 patients available at follow-up, 13 patients had good results and two required additional surgery. Proximal femoral replacement may be useful in low-demand or elderly patients. Survivorship of the proximal femoral replacements has been reported to be 65% at 12 years.49

 

Treatment

Nonoperative treatment is indicated when the fracture is stable, such as in undisplaced trochanteric fractures, or in a patient whose general medical condition precludes surgery.

Type AG and AL (Fig. 37.1). Type A-L fractures reflect poor quality of bone and possible osteolytic or osteoporotic processes. In addition, Type A-L fractures are difficult to reduce and fix, hence are treated symptomatically. In the case of nondisplaced Type A-G fractures, nonoperative care is preferred. Displaced greater trochanter fractures can usually be fixed adequately by cerclage wires supplemented by screws or plates if required These fractures are often associated with osteolysis in the proximal femur, and this should be grafted, usually with morselized allograft, at the time of fixation of the injury.

Type B (Flow chart 37.3)

 

 

B1. This occurs in the region of the tip of a well-fixed stem. Cerclage wires or cables can be used to fix long oblique or spiral fractures. However, supplementary fixation by an onlay cortical strut graft or by a plate provides the facility for fixation both with screws placed distal to the implant and cerclage wires or cables located proximally. If the fracture is short, oblique or transverse, biplanar fixation on the anterior and lateral aspects can be provided combination of plate and cortical strut grafts. The latter are sculpted with a burr to provide

 

Figure 37.1: Radiograph of a 76 years old lady who sustained a periprosthetic fracture of her proximal femur 3 months after a hemiarthroplasty for a fracture neck of femur. The fracture involves the greater and lesser trochanter

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Periprosthetic Fractures After Total Hip Arthroplasty

 

Flow chart 37.3: Management of Vancouver Type B fracture

 

 

 

 

intimate contact with the underlying cortex, which is also roughened.5 Junctional grafting with morselized allograft or bone slurry probably accelerates union. In rotationally unstable transverse fractures it is necessary to achieve unicortical fixation proximally to provide stability.

B2. These fractures occur at the tip of the stem and are associated with a loose implant but reasonable proximal bone stock. Type B2 fractures necessitate revision of the loose femoral component in conjunction with femoral fixation treatment. Fractures must be individualized with bone quality, fracture pattern, and surgeon experience. Proximally coated long-stem modular components, long-stem distally coated stems with or without interlocking screws (Figs 37.2A to C), or long-stem cemented prostheses can be used in these situations depending

 

 

 

 

Figures 37.2A to C: Vancouver Type B2 late periprosthetic femur fracture in a fit 70-year-old managed with revision to long stem with distal screws, cables and bone graft (A) Preoperative X-ray (B and C) Postoperative X-rays demonstrate early healing

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Figures 37.3A to D: Vancouver Type B3 femoral periprosthetic fracture in a 78 years old lady.

(A) Demonstrates a loose cemented femoral stem with poor proximal femoral bone stock and a cemented cup with eccentric polyethylene wear. (B, C and D) 2 year follow-up radiographs demonstrate good healing of the fracture after revision hip replacement with a long stem cementless prosthesis supplemented with cable plate and trochanteric claw fixation (Radiographs courtesy of Mr. H Zahn)

 

Total Hip Arthroplasty

 

on bone quality and patient demand. Cerclage wires and strut allografts can be used to supplement fixation and facilitate bony union of these fractures. It is important to recognize that the bone loss encountered at the time of surgery is likely to be much greater than that predicted from the radiographs.

B3. Periprosthetic fractures in the presence of grossly deficient proximal femoral bone stock and loose stems are the most difficult to treat. If adequate distal fixation in the diaphysis can be achieved, the proximal femur can be collapsed down to embrace the underlying stem. Two cortical onlay grafts can then supplement the fixation and bone stock. Cancellous allograft is used to augment the bone stock further. If this solution is not feasible, it may be necessary to replace the proximal femur with a customised prosthesis in elderly patients or with an allograft-prosthetic composite in the younger age group. This has the advantage of allowing the remnants of the proximal femur to be wrapped around the allograft, which potentially contributes to regional soft-tissue attachment and thus stability and function (Figs 37.3A to D).

Type C. Type C fractures can be treated in a similar manner to any distal femoral fracture. Proximal femoral obstruction precludes antegrade nailing. Retrograde nailing is a suitable option. Supracondylar plates or distal femoral plating with additional strut grafting may encourage healing and maintain stability (Figs 37.4A to D).

 

 

 

 

Figures 37.4A to D: Vancouver Type C Femoral periprosthetic fracture in a 72 years old patient managed with Cable plate and Allograft fixation. (A) Preoperative X-ray (B, C and D) Post-operative X-rays demonstrate healing of the fracture and incorporation of the allograft (Radiographs courtesy of Mr. H Zahn)

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Discussion

Periprosthetic fracture in primary and revision total hip arthroplasty will continue to affect outcomes in hip arthroplasty. Limited visualization in minimally invasive techniques and press-fit components will require care to prevent intraoperative fractures appropriately. The number of implants in the population combined with osteolysis from wear and osteoporosis from age predicts a trend toward future late periprosthetic fractures. Suitable advances and experienced treatment techniques will help achieve the best outcomes.

 

Conclusion

 

Periprosthetic fracture is a potentially serious complication of total hip arthroplasty (THA) that can be difficult to treat, with high risk of complications. Treatment is based on fracture timing, fracture pattern, implant stability and bone quality. Intraoperative fractures are usually stable; to prevent intraoperative fracture, careful preoperative planning and gentle operative techniques are essential. Intraoperative fractures in the femur commonly occur in the peritrochanteric area and are treated by cerclage wiring or cables. Postoperative periprosthetic fractures are usually the result of trauma in the setting of loose implant and/or osteolysis. In managing unstable intraoperative and late postoperative periprosthetic fractures, the surgeon should know the exact pattern of fracture, prosthesis stability, and bone quality. Loose prostheses are revised and displaced fractures should be reduced and adequately fixed. Periprosthetic femoral fractures are classified using the Vancouver classification based on the location of the fracture, the stability of the stem, and the amount of available proximal bone stock. Correct classification of these fractures is important, as it helps to guide treatment.

 

Periprosthetic Fractures After Total Hip Arthroplasty

 

Acknowledgement                    

I wish to acknowledge the contribution of Mr Helmut Zahn, Consultant Orthopaedic Surgeon, William Harvey Hospital for providing radiographs in this chapter.

 

References                       

1. Sharkey PF, Hozack WJ, Callaghan JJ, et al. Acetabular fracture associated with cementless acetabular component insertion: A report of 13 cases. J Arthroplasty 1999;14:426-31.

2. Berry DJ, Lewallen DG, Hanssen AD, et al. Pelvic discontinuity in revision total hip arthroplasty. JBJS 1999;81A:1692-1702.

3. Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr Course Lect 1995;45:293-304.

4. Rayan F, Dodd M, Haddad F. European validation of the Vancouver classification of periprosthetic proximal femoral fractures. JBJS 90-B;12:1576-9.

5. Peterson CA, Lewallen DG. Periprosthetic fracture of the acetabulum after total hip arthroplasty. J Bone Joint Surg 1996;78A:1206-13.

6. Adler E, Stuchin SA, Kummer FJ. Stability of press-fit acetabular cups. J Arthroplasty 1992;7:295-301.

7. Curtis MJ, Jinnah RH, Wilson VD, Hungerford DS. The initial stability of uncemented acetabular components. J Bone Joint Surg Br 1992;74:372-6.

8. MacKenzie JR, Callaghan JJ, Pedersen DR, Brown TD. Areas of contact and extent of gaps with implantation of oversized acetabular components in total hip arthroplasty. Clin Orthop Relat Res 1994;298:127-36.

9. Stiehl JB, MacMillan E, Skrade DA. Mechanical stability of porous-coated acetabular components in total hip arthroplasty. J Arthroplasty 1991;6:295-300.

10. McElfresh EC, Coventry MB. Femoral and pelvic fractures after total hip arthroplasty. J Bone Joint Surg Am 1974;56:483-92.

11. Haidukewych GJ, Jacofsky DJ, Hanssen AD, Lewallen DG. Intraoperative fractures of the acetabulum during primary total hip arthroplasty. J Bone Joint Surg Am 2006;88:1952-6.