Hip Int 2014; 24 ( 6): 556-567

DOI: 10.5301/hipint.5000155

REVIEW

Periprosthetic femoral fractures in total hip arthroplasty Nicholas E. Ohly1, Michael R. Whitehouse2, Clive P. Duncan3 Royal Infirmary of Edinburgh, Edinburgh - UK University of Bristol, Bristol - UK 3 The University of British Columbia, Department of Orthopaedics, Vancouver - Canada 1 2

Periprosthetic fractures in total hip arthroplasty (THA) are a significant problem facing hip surgeons, and were responsible for revision surgery in 9% of single stage revision THAs recorded in the National Joint Registry of England and Wales (NJR) in 2012; the 5th most common cause after aseptic loosening, osteolysis, pain and dislocation. The incidence has increased along with the number of THAs performed. Implants and techniques of THA continue to evolve, surgical indications are expanding and the number performed annually continues to rise. Furthermore, patients are undergoing THA earlier and living longer, leading to a rise in the average number of years at risk for periprosthetic fracture. In this review we will discuss the epidemiology of femoral periprosthetic fractures, their prevention, classification and the evidence base for their treatment. Keywords: Total Hip Replacement, Periprosthetic fractures Accepted: April 15, 2014

INTRODUCTION

EPIDEMIOLOGY

Periprosthetic fractures in total hip arthroplasty (THA) are a significant problem facing hip surgeons, and were responsible for revision surgery in 9% of single stage revision THAs recorded in the National Joint Registry of England and Wales (NJR) in 2012 (1); the 5th most common cause after aseptic loosening, osteolysis, pain and dislocation. The incidence has increased along with the number of THAs performed. Implants and techniques of THA continue to evolve, surgical indications are expanding and the number performed annually continues to rise. Furthermore, patients are undergoing THA earlier and living longer, leading to a rise in the average number of years at risk for periprosthetic fracture. In this review we will discuss the epidemiology of femoral periprosthetic fractures, their prevention, classification and the evidence base for their treatment.

Periprosthetic fractures of the femur can be divided into early (intraoperative) and late. Intraoperative periprosthetic fractures are more common in revision than primary surgery and with the use of uncemented compared to cemented implants. In 2012 the NJR reported an incidence of 0.83% for intraoperative femoral fractures during primary THA (1), most commonly a medial calcar crack or trochanteric fracture. Berry reported an incidence of 0.3% for intraoperative periprosthetic fractures in 20,859 cemented THAs and 5.4% in 3,121 uncemented THAs (2). During revision THA the respective incidences were 3.6% in 4,813 cemented revisions and 20.9% in 1,536 uncemented revisions (2). These rates were similar to the findings of Morrey et al who reported an incidence of 3.2% for cemented revision (in 94 cases) and 18.1% for uncemented revisions

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(3). Meek et al reported an incidence of 30.3% in 211 revision THAs with the use of long diaphyseal uncemented implants (4). The implant designs and techniques used in these different studies all have an influence on the risk of fracture. The risk of intraoperative femoral fracture is influenced by the method of fixation. Uncemented fixation necessitates more forceful broaching and implant insertion in order to achieve satisfactory press fit stability to allow subsequent bone ingrowth, this leads to an increased incidence of fracture during preparation and stem insertion than in cemented stems. The type of uncemented implant also plays a role in determining the fracture pattern. Proximally coated implants are more likely to induce a metaphyseal fracture, most commonly a medial calcar crack (1), whereas more extensively coated implants relying on diaphyseal fit are more likely to create a shaft fracture. The following factors have been identified by various authors as increasing the risk of periprosthetic fracture during revision THA: osteoporosis, severe bone loss, low cortex-to-canal ratio, femoral deformity, excessive torsional force during dislocation, removal of well-fixed implants, cortical defects (e.g. from screws, previous hardware, osteotomies or iatrogenic perforation), under-reaming the femur, the use of larger stems, and the use of uncemented implants (especially longer stems) (2, 5-9). The incidence of postoperative fracture reported in studies varies according to the period of follow up, patient demographics, implants and techniques used, the completeness of the follow up and the thresholds used for

diagnosis and surgical intervention when the risk of fracture is identified. A summary of the reported incidence of postoperative femoral periprosthetic fractures following primary THA is shown in Table I and for revision THA in Table II. Where data is available, the mean time to fracture is given in the table rather than the mean period of follow up as this is not sufficiently well described in the majority of the papers included. The mean time until fracture tends to decrease as the number of previous revision THAs rises (10). The prevalence of periprosthetic fractures appears to be increasing (2, 11-13), this may simply reflect the aging population who are more likely to have osteoporosis and an increased risk of fracture; the risk ratio for fracture increases by 1.01 per year of aging (14). There is also an increase in osteolysis and prosthetic loosening with time after THA (11, 14, 15) and both of these are known risk factors for fracture (10). Loosening prior to fracture has been reported in between 50–75% of cases (16-18). Low-energy falls led to the fracture in 75% of primary cases and 56% of revision cases (10). Fracture due to high-energy trauma is rare, accounting for only 7% in both groups. Falls in the home account for 66% and outdoors 18% (19). There has been a common perception that the incidence of fracture is higher in female than male patients (20, 21) but the evidence to support this is weak. Analysis of registry level data shows an equal distribution by gender (10, 22). The indication for primary surgery influences the risk of subsequent fracture, and there is a higher risk following THA for rheumatoid arthritis and femoral neck fracture (10, 22).

TABLE I - SUMMARY OF PUBLISHED REPORTS OF THE INCIDENCE OF POSTOPERATIVE FEMORAL PERIPROSTHETIC FRACTURES FOLLOWING PRIMARY THA Author and year

Mean time to fracture (years)

Number of fractures

Number of cases

% incidence

Berry 1999 (2)

N/A

262

23,980

1.1%

Cook 2008 (89)

6.3

124

6,458

1.9%

Fredin 1987 (17)

4.8

11

1,961

0.6%

Lindahl 2005 (10)

7.4

688

216,226

0.3%

Lowenhielm 1989 (90)

3.1

14

1,442

1.0%

Meek 2011 (9)

3.0

508

52,136

1.0%

Wu 1999 (15)

N/A

16

454

3.5%

N/A = not applicable, insufficient data provided or reporting. © 2014 Wichtig Publishing - ISSN 1120-7000

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TABLE II - SUMMARY OF PUBLISHED REPORTS OF THE INCIDENCE OF POSTOPERATIVE FEMORAL PERIPROSTHETIC FRACTURES FOLLOWING REVISION THA Author and year Berry 1999 (2)

Mean time to fracture (years)

Number of fractures

Number of cases

% incidence

N/A

252

6,349

4.0

N/A

4.0

Kavanagh 1992 (91) Lindahl 2005 (10)

3.9

361

19,620

1.8

Meek 2011 (9)

2.0

360

8,726

4.1

Singh 2012 (92)

5.6

330

6,281

5.3

N/A = not applicable, insufficient data provided or reporting.

PREVENTION Prevention of periprosthetic fractures in THA begins preoperatively. The risk factors discussed above should be identified and the patient appropriately counselled regarding the risk of fracture. Preoperative templating should be carried out to ensure the suitability of the planned implants for the host anatomy and to identify any potential stress risers to ensure these are sufficiently bypassed. Insufficient visualisation intraoperatively is associated with an increased risk of periprosthetic fracture (23). A variety of extensile approaches have been described to allow the surgeon sufficient access during the operation to reduce the risk of fracture, such as extended trochanteric osteotomy (24). During surgery, a fracture may occur during hip dislocation, reaming, broaching, hip reduction or insertion of the definitive implants. In revision surgery, fracture may also occur during implant removal. Protrusio increases the risk of femoral fracture during dislocation. Controlled removal of part of the posterior wall or in situ femoral neck osteotomy may be required to avoid fracture. Stress risers increase the risk of fracture during dislocation manoeuvres. In such cases, dislocation of the hip with the metalwork in situ, followed by hip reduction, removal of metalwork then redislocation can reduce the risk of fracture. The greater trochanter is at risk of fracture, particularly during removal of the femoral component. Adequate clearance of soft tissue from the shoulder of the femoral component should be performed before attempted removal of the prosthesis. If bone overhangs the shoulder, a channel should be created to allow passage of the femoral component. This is typically achieved with the use of rongeurs, osteotomes or a high-speed burr. Leaving the femoral prosthesis in situ during acetabular reconstruction may reduce the risk of frac558

turing a weakened femur. This also minimises the blood loss that can ensue from a wide bed following osteotomy and implant removal. Femoral components may be successfully removed from the proximal aspect of the femur. Slip-taper polished cemented stems may be reverse impacted prior to cement removal. Composite beam stems require removal of at least a portion of the cement mantle before they can be reverse impacted safely, unless grossly loose. The cement mantle may be safely removed using specialised cement removal instruments, which may include osteotomes, splitters, burrs, hooks and threaded taps. Uncemented implants may be removed using a combination of high-speed burrs, long drills and flexible osteotomes. Additional exposure may be required in more difficult cases where the prosthesis or cement is well-fixed. Techniques such as cortical windows or controlled perforations allow access to the construct/bone interface or reverse impaction of cement or prostheses. Trochanteric osteotomy allows wide exposure, straightforward cement removal, accurate location of the medullary cavity, accurate alignment of long revision components and deformity correction where required (25). Any defect created during cement and implant removal must be bypassed by two femoral cortical diameters in order to reduce the risk of subsequent fracture (26). There is no benefit in bypassing the stress riser by more than two femoral diameters and this may be associated with a reduced resistance to torsional force (5). The surgeon should be alert to changes in note during impaction, sudden changes in the apparent stability of trials or implants, sudden advancement of broaches, trials or implants or advancement beyond the pre-planned and trialled levels. Judicious use of guide wires and intraoperative radiographs is recommended to ensure that perforations or defects

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Fig. 1 - The Vancouver classification of post-operative peri-prosthetic femoral fractures: A) type AG and AL; B) type B1; C) type B2; D) type B3; E) type C. (Adapted with permission from Garbuz DS, Masri BA, Duncan CP. Fractures of the femur following total joint arthroplasty. In: Steinberg ME, Garino JP, eds. Revision total hip arthroplasty. Philadelphia: Lippincott Williams & Wilkins, 1999; 497).

are recognised and broaches and implants are positioned appropriately.

CLASSIFICATION (Fig. 1) A variety of classification systems for femoral periprosthetic fractures involving THAs have been described (16, 20, 27-29). The most commonly used and widely accepted system is the Vancouver classification (30). In the development of this system, the authors of the classification utilised the three most important variables in determining treatment. The classification is based upon the site of the fracture, the stability of the stem and the bone stock available for reconstruction. The classification has been demonstrated to be reliable and valid (31-33). The classification divides the femur into three anatomically distinct regions: •  Type A The trochanteric region; •  Type B The diaphysis and the region just distal to the tip of the stem; •  Type C The diaphysis well distal to the tip of the stem. Type A fractures are subdivided by location into AG or AL for those affecting the greater or lesser trochanters respectively. Type B fractures are further subdivided depending upon the stability of the stem and the bone stock around the stem: Type B1 – stable femoral component and adequate bone stock; Type B2 – loose femoral component and adequate bone stock; Type B3 – loose femoral component

and inadequate bone stock. Type C fractures occur well distal to the tip of the femoral stem or construct and may be treated as separate fractures. Lindahl et al studied the relative frequency of fracture type in a large joint registry (10) (Tab. III). The majority of the fractures were types B1 or B2. Type B2 fractures were three times more common following primary THA than in revision THA. Type B2 fractures were also noted to be more common in older patients.

PRINCIPLES OF TREATMENT Minimally displaced AG fractures can be considered stable due to the digastric action of the gluteal muscles and vasti, these fractures can be treated with restriction of weight bearing and active abduction as indicated by the patient’s level of symptoms. This stability may be lost with further displacement leading to the need for reduction and fixation. Pritchett demonstrated that AG fractures displaced by less than 2 cm may be successfully treated conservatively (34). If the greater trochanter is severely osteolytic, bearing surface exchange may be required to remove the wear debris generator. The opportunity to bone graft the greater trochanter is taken at the same time. True AL fractures (that do not involve the medial cortex) represent an avulsion fracture by iliopsoas and are treated symptomatically, not usually requiring operative intervention. It is important to recognise and appreciate a distinct variant of the radiological appearance of the AL, the pseudo-AL type representing a B2 fracture with loss of medial support and compromise of stem stability requiring revision of the stem (35).

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TABLE III - FREQUENCY OF FRACTURE CLASSIFICATION FOR PRIMARY AND REVISION THA IN THE SWEDISH ARTHROPLASTY REGISTER (10) Vancouver Category

Primary THAs (n = 688)

Revision THAs (n = 361)

Total (n = 1049)

A

5% (32)

4% (15)

4% (47)

B1

21% (146)

44% (158)

29% (304)

B2

61% (417)

38% (138)

53% (555)

B3

4% (31)

3% (12)

4% (43)

C

9% (62)

11% (38)

10% (100)

B1 fractures can be successfully managed by open or closed reduction and internal fixation as dictated by displacement and ease of reduction. Minimally invasive reduction requires less soft tissue stripping (36, 37). Onlay cortical strut grafts can be used to augment fixation during open reduction. Loosening of the implant can usually be determined on the preoperative plain radiographs, however it is essential to assess stem stability intraoperatively. A fracture that extends through the cement mantle around a cemented stem will compromise the stability of that stem and should be categorised as a type B2. In type B2 fractures the implant is loose and requires revision as part of the reconstruction. The chosen implant needs to be stable and the risk of further fracture minimised and therefore stress risers should be bypassed by at least two femoral outer cortical diameters. The surgeon should choose the technique and implant with which they are most familiar and this may reasonably include either uncemented or cemented fixation (+/-impaction grafting). In managing inherently unstable transverse fracture patterns it may be advantageous to use onlay cortical strut grafts to augment the intramedullary fixation achieved by the implant. For long oblique or spiral fracture patterns, cerclage fixation alone may be sufficient. In type B3 fractures, not only is the stem loose, but the quality of the remaining bone stock is compromised necessitating more advanced techniques to bypass or replace the deficient bone stock. Revision options include secure distal fixation with complex reconstruction of the deficient proximal femur, segmental substitution of the proximal femur with a tumour prosthesis or allograft-prosthesis composite, or a distally fixed prosthesis with scaffold reconstruction of the proximal femur around the modular device (38). Type C fractures may be addressed by osteosynthesis techniques in most cases. If such a fracture occurs distal to a 560

loose stem, a relatively unusual scenario, it is reasonable to first address the fracture and achieve satisfactory union before returning to address the loose stem as a planned elective procedure. These patients must be followed closely postoperatively.

OUTCOMES OF TYPE B AND C POSTOPERATIVE PERIPROSTHETIC FRACTURES Type B1 fractures The use of onlay cortical strut allografts in the treatment of periprosthetic fractures has been in common usage for two decades (39-41). Chandler et al reported the results of 19 patients treated with the use onlay strut grafting (39). At 4.5 months postoperatively, anatomical union was achieved in 16 cases, a mild malunion in one case and nonunion requiring further revision occurred in two cases. This group subsequently went on to recommend the incorporation of a lateral compression plate in combination with strut grafting in some cases (40). Haddad et al reported excellent results with the use of onlay cortical strut grafts with or without the use of a supplementary lateral compression plate (42). Union was achieved in 39 out of 40 cases with one failure (due to fracture of the plate and graft) in a patient who was non-compliant with rehabilitation recommendations. Malunion of less than 10° occurred in four cases and deep infection in one case. The ability to create congruency between the graft and the host femur and the approximately equal modulus of elasticity between the graft and the host bone were highlighted as important factors. Ricci et al reported the results of 41 patients treated with a minimally invasive percutaneous plate osteosynthesis

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technique at an average of 24 months following fixation (36). A single lateral plate construct without bone grafting was used in all cases. Union was achieved at 7–23 weeks. Three patients experienced breakage of some element of the hardware (one cable and one screw in each of two patients) but went on to heal, and there was one perioperative infection. Such encouraging results have not been universally achieved in the case of lateral plate fixation only. Buttaro et al reported the results of a series of 14 patients, in nine a lateral plate only was used and in five this was augmented with an anterior strut graft. Failure occurred in six of the nine cases treated with a lateral plate alone (three plate fractures, three plate pull outs). Fracture union occurred at an average of 5.4 months in the eight cases that healed. Ebraheim et al reported the results of 13 type B1 fractures treated with a reversed distal femoral locking plate, union was achieved in all cases at an average of 14 weeks (43). Two infections occurred in the series. The Dall-Miles cable plate system has been a popular mode of treatment of this fracture pattern. Venu et al reported the use of this system in combination with various types of grafting and union was achieved in nine out of 12 cases (44). Tadross et al drew attention to the risk of nonunion in such cases with malunion in two and nonunion in two out of seven cases in their series (45). They highlighted the risk of a varus femoral stem leading to fracture distraction. Single locked lateral plate fixation can also be successful in the challenging case of interprosthetic fracture between well fixed total hip and knee replacements (the so called type D fracture (46)) with union achieved in all 22 cases in ones series at an average of 14 weeks postoperatively (47). This is despite early concerns in the treatment of these fractures, with all four cases in one early series failing (48).

Type B2 fractures The differentiation between B1 and B2 fractures is important (49). Although Kamineni et al highlighted the treatment of B2 fractures around cemented components with plates and cables as a successful technique, four out of their series of 15 cases required revision. One of these was due to hardware failure but three achieved union before requiring revision. We strongly recommend that loosening be adequately addressed by revision surgery at the time of definitive treatment to reduce the risk of subsequent revision. This is corroborated by the work of Beals and Tower,

who in a series of 93 periprosthetic fractures noted better results in the treatment of B2 and B3 fractures when the stem was revised with additional fixation as required (19). Lower complication rates were noted with uncemented revision components than cemented. In Lindahl et al’s study of 1049 periprosthetic fractures (50), there were 245 re-revisions in this group and a significantly higher rate of failure noted in B1 fractures compared with any other type with the most important factor being the use of a single plate. The authors noted that misdiagnosis of B2 fractures as B1s probably lead to this high failure rate by stem loosening and advised assuming any B1 fracture was a B2 until proven otherwise. A reduced risk of failure was noted in B2 fractures compared to the other types if the stem was revised with or without internal fixation. A lower risk of failure was noted if a long cemented Lubinus stem or a long uncemented Bi-Metric stem were used whereas the use of long distally fixed prostheses (Wagner and Lubinus MP), the cemented Charnley or cemented Exeter stem did not affect the risk. Mont and Marr summarised the early results of the literature on the treatment of periprosthetic fractures (51). They presented data on 487 cases and determined that cerclage wiring or cables with bone graft or long stem revision was the preferred option for type B2, B3 and C fractures (in the latter group, they stated that traction was equally successful). Tsiridis et al studied the results of cemented revision and impaction grafting in a series of 106 patients with B2 or B3 fractures (52). Union rates of 88% were achieved when a cemented stem that bypassed the fracture was combined with impaction grafting. Lower rates of union were achieved if the stem did not bypass the fracture or impaction grafting was not used. There were four infections in the series. Lindahl et al reported on the results of 321 periprosthetic femoral fractures of which 192 were B2 or B3 (53). They found no difference in the failure rate between the use of long cemented (75% of cases) or long distally-fixed uncemented implants (25%). Tower and Beals reported that the success rates were higher when a modular proximal ingrowth stem with a long fluted distal stem for torsional control was used compared to cemented fixation (29). They suggested that a fully coated diaphyseal stem would give similar control. MacDonald et al reported the results of 14 periprosthetic fractures treated with long uncemented canal filling components (54). They reported no re-revisions although one stem had stable fibrous ingrowth and one stem was not stable but

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was not symptomatic enough to require revision. Incavo et al reported no cases of loosening in five out 14 cases of type B2 and B3 fractures treated with long uncemented distal fixation stems (four fully porous coated, one tapered) whereas four of seven cases that utilised stems reliant on proximal stability failed despite the use of morcellised graft and strut grafts (55). Two cases in this series required the use of whole femoral allografts. Levine et al reported the results of 14 cases of B2 or B3 fractures managed with an extended trochanteric osteotomy (ETO) and the use of a modular tapered stem (four cases) or a fully coated straight or bowed stem (13 cases; three cases lost to follow-up) (56). All cases went on to union of the ETO and osseointegration of the stem but initial subsidence was seen in two of the modular tapered stems compared to one fully coated stem. Quality of life and functional outcomes have been shown to be better with the use of a modular tapered fluted titanium stem than with the use of cylindrical extensively coated cobalt-chrome stems in the context of revision total hip arthroplasty (57).

Type C fractures

Type B3 fractures In the treatment of type B3 fractures, the use of complex proximal femoral reconstruction is limited by the nature of the poor bone stock. Gross popularised the use of allograftprosthesis composites to reconstruct or replace proximal bone deficiency (58). His group presented a series of 25 B3 fractures at a mean follow up of 5.1 years (59). Twentyone of the cases had not required revisions and 21 of the 24 patients reported no or mild pain. Union of the greater trochanter was achieved in 17 and distal union in 20. The disadvantage of such constructs is the prolonged time until full weight-bearing, which can be problematic in the elderly patient who typically sustains a B3 fracture (60). Although adaptations of the technique may provide early stability (61), these only apply to a minority of cases due to the size of the femur required. The use of an endoprosthesis affords the advantage of early stability and therefore the ability to weight-bear (62, 63). Survivorship of over 70% at five years has been demonstrated (64). Although the use of such prostheses does not achieve equivalent function to conventional revision THA (65) and is associated with a higher complication rate (66), their use is reserved for a more complex problem than is addressed in conventional THA and the improvement in other measures of quality of life are equivalent. Particular attention should 562

be paid to hip stability intraoperatively, which is improved by retention and fixation of the abductor mechanism. Constrained acetabular devices may be necessary to ensure satisfactory stability. A third method is revision with a distally fixed prosthesis and scaffold reconstruction of the proximal femur around the modular device (57, 67-69). Short to medium term results have been encouraging but it is vital to ensure that sufficient implant stability is obtained with scratch fit in the isthmus. Whilst the Wagner concept stated that this must be between 70 and 100 mm, the nature of the fit within the isthmus appears to be important and when using an ETO for access, a three point fixation within the isthmus must be avoided (70). This can be achieved by not using a stem that is longer than necessary to achieve a good scratch fit and using an ETO that is long enough to provide sufficient access to the intramedullary canal without compromising the isthmus available. In our centres we aim to achieve a 50 mm scratch fit or two cortical diameters.

Conservative treatment of type C fractures leads to significant problems with malunion, high complication rates and prolonged hospital stay (71). Reduction and fixation using locking plates is the gold standard in managing this type of fracture (72-74). There is some weak evidence that the rate of complications may be higher when open reduction and internal fixation is utilised when compared to revision arthroplasty in type B1 and C fractures (75). This study was limited by an uneven distribution of treatments in the C type fractures, inconsistent reporting of case numbers in the paper and the influence of the potential misdiagnosis of B1 and B2 fractures. Currall et al reported the results of five patients treated with the LISS femoral locking plate in combination with bone grafting and cables for type C fractures (73). All cases went on to union and four out of five cases were able to mobilise independently, there was one superficial wound fection reported. Kobbe et al reported the results of a series of 16 patients with B1 or C (n = 8) fractures treated with the LISS system (74). Good functional results were reported but there was one failure in the C group due to screw pull out. Chakravarthy et al reported the results of a series of 12 type B1 and C (n = 6) fractures treated with either an LCP or LISS locking system (72). One patient died in the early postoperative period and union was achieved in 10 of the remaining 11. There were

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Fig. 2 - The Vancouver classification of intra-operative peri-prosthetic femoral fractures (Used with permission from Gooding CR, Garbuz DS, Masir BA, Duncan CP. Periprosthetic fractures: prevention/diagnosis/treatment. In: Berry DJ, Lieberman JR, eds. Surgery of the hip. Philadelphia: Saunders, 2013; 1226).

two failures, both in type C fractures with one device failing before union and one after union.

INTRAOPERATIVE PERIPROSTHETIC FRACTURES (Fig. 2) The Vancouver group provided subsequent modification to the above classification system so that it could be applied to intraoperative periprosthetic fractures (41, 76). The anatomical classification of the fracture remained the same as above: •  Type A Trochanteric region; •  Type B Diaphysis and the region just distal to the tip of the stem; •  Type C Diaphysis well distal to the tip of the stem. Each fracture type was then subdivided according to pattern: 1. Simple cortical perforation; 2.  Undisplaced linear fracture; 3.  Displaced or unstable fracture. Type A1 fractures are stable and unlikely to affect the stability of the stem. These can either be ignored or packed

with autograft. Type A2 fractures occur at the time of broach or definitive stem impaction. The proximal aspect of the femur represents a “napkin ring” during broach and stem impaction and this is carefully observed throughout for any sign of fracture. A fracture may occur due to continued impaction once the broach or stem achieves a snug fit against the medial calcar. If a fracture is identified, the extent of propagation is confirmed by direct inspection with or without intraoperative radiographs. If such a fracture is identified, the broach or stem should be removed. If the fracture line is undisplaced and does not compromise stability of the stem, a cerclage wire or cable should be placed to hold the fracture reduced and prevent propagation. If further propagation is noted at the time of stem insertion or the stem is not stable to testing once inserted, the fracture should be bypassed with a stem that will achieve sufficient distal fixation (77). Type A3 fractures may affect either trochanter and are unstable. If the fracture extends into the metaphyseal region of the proximal femur, this should be bypassed to obtain sufficient distal fixation. Stability of the fracture can be achieved by cerclage wires or cables. Greater trochanter fractures may be reattached using the surgeon’s preferred technique, which may include cerclage wires, cables or claw plates and cables (78-83). In the case of revision hip replacement where a proximal femoral os-

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teotomy is required for access or component removal (84), an unplanned further fracture to the medial metaphysis may occur due to soft tissue tension or excessive retraction. In most cases, a stem that sufficiently bypasses this area will already have been planned. If it has not, it should be adopted. Once the fracture is bypassed, the fracture can be reduced and held with wires or cables. In the setting of poor bone stock, the fragment can be protected with a cortical onlay strut graft to prevent “cheese-wiring” of the trochanteric fragment (42). Type B1 fractures are cortical perforations of the diaphyseal cortex. These are often created when surgical fixation devices are removed leaving defects. They may also be created intentionally as cortical windows to aid the removal of cemented or uncemented implants or they may be created unintentionally during the trephine over well-fixed implants or the removal of pedestals or distal cement. Type B2 fractures are undisplaced linear cracks typically occurring during broaching or femoral stem insertion. Both of these defects act as stress risers and the surgical reconstruction needs to bypass them by at least two cortical diameters such that a postoperative fracture does not occur at the same site (5). For type B1 and B2 fractures, a wire or cable can be placed proximal to and if necessary distal to the defect prior to broaching or impaction of the stem to prevent fracture propagation during insertion (85). Type B3 fractures are displaced diaphyseal fractures and typically occur during the application of torsional force. Anatomical reduction of the fracture is preferred and then the fracture is held in its reduced position with cables or wires. In the event that any type B fracture occurs below the level that can be bypassed with the available implants, cortical

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onlay grafts or plates can be used to bridge and bypass the defect (42, 86). If the defect is not anatomically reduced, any remaining defect should be filled with bone graft. Type C fractures occur well distal to the tip of the stem. Type C1 fractures are unusual but may occur with the removal of implants or when a long distal cement plug is removed. It is prudent to bone graft such defects and if there is any concern about having created a significant stress riser, then a cortical onlay graft can be used. Type C2 fractures can be treated with the use of cerclage wires or cables with or without the use of an onlay cortical graft as is indicated by the bone stock present. Type C3 fractures are displaced but cannot be bypassed by the available implants. Such fractures should be addressed by open reduction and internal fixation (73) or minimally invasive techniques when appropriate (87). Fixation utilising plates with distal bicortical screws and proximal unicortical screws with or without cables provides significantly more stability in axial compression, lateral bending and torsional loading than alternatives (88). Financial Support: None. Conflict of Interest: None. Address for correspondence: Michael R. Whitehouse Clinical Lecturer in Trauma and Orthopaedics University of Bristol Musculoskeletal Research Unit Lower level AOC Southmead Hospital Westbury-on-Trym Bristol, BS10 5NB, UK [email protected]

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Meek RMD, Garbuz DS, Masri BA, Greidanus NV, Duncan CP. Intraoperative fracture of the femur in revision total hip arthroplasty with a diaphyseal fitting stem. J Bone Joint Surg Am. 2004;86(3):480-485. Larson JE, Chao EY, Fitzgerald RH. Bypassing femoral cortical defects with cemented intramedullary stems. J Orthop Res. 1991;9(3):414-421. Schmidt AH, Kyle RF. Periprosthetic fractures of the femur. Orthop Clin North Am. 2002;33(1):143-152, ix. Garbuz DS, Masri BA, Duncan CP. Periprosthetic fractures of the femur: principles of prevention and management. Instr Course Lect. 1998;47:237-242.

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Periprosthetic femoral fractures in total hip arthroplasty.

Periprosthetic fractures in total hip arthroplasty (THA) are a significant problem facing hip surgeons, and were responsible for revision surgery in 9...
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