Periprosthetic Femoral Fractures Associated With Total Hip Arthroplasty

CASE STUDY

A 92-year-old woman sustained an injury to her left lower extremity after falling from a standing position. Her surgical history is significant for a left hybrid total hip arthroplasty with a cemented femoral stem that was performed 15 years earlier.

Physical examination revealed shortening and deformity of the affected extremity with no neurovascular deficits. Injury radiographs were obtained ( Figs. 71.1 and 71.2 ). The injury pattern was consistent with a Vancouver B2 periprosthetic femoral fracture. The patient underwent surgery for removal of the cement and femoral component, which was revised to a tapered, fluted, modular titanium stem and cerclage cabling ( Figs. 71.3 to 71.5 ; see Fig. 71.2 ).

$FIGURE 71.1, Anteroposterior radiograph of a 92-year-old woman after a fall shows a displaced and shortened Vancouver type B2 periprosthetic fracture of a hybrid total hip arthroplasty.$

FIGURE 71.2, A cross-table lateral radiograph shows the injury of the patient in Figure 71.1 .

FIGURE 71.3, The previous femoral stem and cement mantle were removed. The postoperative anteroposterior radiograph of the pelvis shows the femur that was reconstructed with a cementless, tapered, modular, fluted titanium stem.

FIGURE 71.4, Postoperative anteroposterior radiograph of the left hip.

FIGURE 71.5, Postoperative anteroposterior radiograph of the left femur.

Algorithms

$This algorithm correlates the Vancouver classes of periprosthetic femoral fractures with treatment options. APC , Allograft prosthetic composite; ORIF , open reduction and internal fixation.$

$This algorithm outlines the approach to treatment of periprosthetic femoral fractures. APC , Allograft prosthetic composite; ORIF , open reduction and internal fixation.$

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Chapter Synopsis

The indications, surgical technique, complications, and outcomes are described for treatment of periprosthetic fractures of the femur in cases of total hip arthroplasty (THA).

Important Points

Proper interpretation of preoperative radiographs and classification of the periprosthetic fracture can guide the surgeon in choosing the most appropriate reconstruction.
Surgical exposure and radiographs are used to fully assess the periprosthetic fracture.

Clinical/Surgical Pearls

We prefer a posterior approach to the hip for revision THA.
The distal femur can be accessed through a posterolateral approach.

Clinical/Surgical Pitfalls

Misinterpretation and treatment of a Vancouver B2 fracture as a B1 can lead to failure if treated with open reduction and internal fixation.

Introduction

Periprosthetic fracture is a known complication of total hip arthroplasty (THA). Periprosthetic fractures can occur intraoperatively and postoperatively. The reported incidence of intraoperative periprosthetic fractures of the femur in primary THA ranges from 0.3% to 1.0% with the use of cemented femoral components and 3% to 20% with the use of cementless femoral components. Revision THA carries a greater risk of intraoperative periprosthetic fracture, with an incidence of 3.6% to 6.3% with the use of cemented femoral components and 17.6% to 20.9% with the use of cementless femoral components. Revision of the femoral component with impaction allografting carries a potential risk of periprosthetic fracture ranging from 4% to 32%. Postoperatively, the risk of periprosthetic fracture for primary and revision THAs is 1% and 4%, respectively.

Local and systemic risk factors predispose patients to periprosthetic fractures. Local risk factors include the use of press-fit femoral components, minimally invasive surgical techniques, complex deformities, osteolysis, cortical stress risers, loose femoral components, and revision surgery. Systemic risk factors include osteopenia, osteoporosis, rheumatoid arthritis, osteomalacia, Paget disease, osteopetrosis, osteogenesis imperfecta, thalassemia, and neuromuscular disorders such as parkinsonism, poliomyelitis, neuropathic arthropathy, cerebral palsy, myasthenia gravis, seizure disorder, and ataxia. Patients awaiting revision THA are often less active or mobile, predisposing them to disuse osteopenia, which can increase their risk of periprosthetic fracture.

The patient’s sex, age at the time of surgery, and length of time since the index surgery have been identified as risk factors predisposing to periprosthetic femoral fracture. A review of 6458 patients who underwent primary THA with cemented femoral components demonstrated an incidence of periprosthetic fracture of 0.8% at 5 years and 3.5% at 10 years. Patients older than 70 years at the time of surgery had a 2.9 times greater risk of sustaining a periprosthetic fracture compared with younger patients. This risk increased to 4.4 times that of younger patients when patients were older than 80 years at the time of primary THA. A separate study evaluated the cumulative incidence of periprosthetic femoral fracture in a consecutive series of 326 patients (354 hips) with an uncemented femoral prosthesis using long-term survivorship analysis. The study authors found a cumulative incidence of periprosthetic femoral fracture of 1.6% at 10 years and 4.5% at 17 years after primary THA.

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