Total hip arthroplasty offers a reproducible alternative to individuals who have painful arthritis of the hip. The advancements in medicine have improved patient outcomes in arthroplasty and decreased hospital length of stay. Cooperation with the anesthesia department has revolutionized perioperative and postoperative pain management to limit narcotic use. Interprofessional preoperative management with the primary care team seeks to optimize a patient before surgery or delay patients unfit for elective arthroplasty. Improved patient selection and widespread availability of implants have allowed primary total hip arthroplasty to be performed in patients of a wide age range and often completed as an outpatient surgery. The desire for primary total hip arthroplasty is predicted to rise from 329,000 to 572,000 operations in 2030, a 174% rise from 2005. A focus on individual health and preventative medicine combined with medical advancements, patients are surpassing previously established life expectancies. The increased utilization in total hip arthroplasty has led to a concurrent increase in periprosthetic fractures. Operative fixation of a periprosthetic fracture is taxing surgery that is best suited for surgeons with a significant volume of related procedures and understanding of the complexities of the operative planning.
Periprosthetic fractures have an increased prevalence in:
The overall incidence of periprosthetic proximal femur fractures ranges from 0.1 to 18%. Revision arthroplasty, surgical technique, and implant type each can increase the incidence of fracture. Canton et al. found that revision total hip arthroplasty often requires extensive soft tissue and bony dissection and raises the incidence of periprosthetic fracture to 4% to 11%. Kurtz et al. found that inadequate bone stock, overzealous femoral bone preparation, and mismatch between component and patients anatomy accounts for an intraoperative fracture risk of 1.7% for primary total hip arthroplasty (THA). Osteolysis, continuous bone loss, and stress shielding at the proximal femur raises the incidence of periprosthetic proximal femur fracture after primary THA at 20 years to 3.5%.
Capone et al. found that intraoperative periprosthetic femur fractures account for 1.7% of primary and 12% of revision total hip arthroplasties. Operative technique and surgical experience have a significant effect on the risk of intraoperative fracture. Abdel et al. found fourteen times increased rate of intraoperative fracture when a cementless femoral stem is used for primary THA. They also found the risk of periprosthetic proximal femur fracture is associated with specific implant designs. A monoblock cup, elliptical cup, and metaphyseal fit femoral stem with extreme taper angles increase the risk of fracture.
In the postoperative setting, minor trauma accounts for the majority of presentations of periprosthetic fractures. At-risk patients include those with osteoporosis, metabolic disease, medication-related bone loss, and substance abuse. Stress shielding of the proximal femur weakens the bone adjacent to an implant and creates a stress rise susceptible to fracture. The majority of total hip implants are a combination of a few metals, such as cobalt and chromium. Cuppone et al. evaluated the elastic modulus of cortical bone and that of a mixed metal arthroplasty component. Their study found the difference in elastic modulus from the surrounding cortical bone to be 7.7% that of the femoral component.
A significant number of patients who present with periprosthetic fractures will sustain their injury performing activities of daily living and rarely report considerable trauma associated with their presentation. A thorough history of recent injuries often reveals a history of fragility fractures. Patient presentation is highly variable. Many patients present with intractable thigh or leg pain and an inability to ambulate while some present to the office with vague thigh pain but still able to ambulate. The physical exam varies between patients, but visible deformity is not easily recognizable secondary to the significant soft tissue surrounding the femur. Neurovascular injury is uncommon in these fractures but is evaluated and documented in every orthopedic patient.
The appropriate evaluation of a periprosthetic proximal femur fracture includes x-ray assessment of the extremity from hip to ankle. Adequate visualization of the ipsilateral hip and knee is critical for determining what implants would be available to the performing surgeon. Thompson et al. stressed the importance of determining whether the implant has subsided from its position on primary arthroplasty. Orthogonal imaging of the hip may not always provide adequate imaging for preoperative planning. If warranted, a computed tomography (CT) scan may be ordered and has the benefit of fine detail with three-dimension reconstitution possible. Previous operative report or familiarity with the radiographic appearance of standard arthroplasty implants dramatically increases the ability to preoperative plan. The performing surgeon should be comfortable with a variety of surgical options ranging from in-situ fixation, revision femoral arthroplasty, proximal femoral replacement, and in rare situations, Girdlestone resection arthroplasty.
Classification systems play a significant role in orthopedics, and most fractures in the body have a classification system designed to dictate treatment. The Vancouver classification is a reliable and accurate tool that guides therapeutic plans. Naqvi et al. reviewed forty-five radiographs of patients with postoperative periprosthetic femur fractures and found an 81% interobserver agreement when classifying B1, B2, and B3 fractures. The Vancouver classification was initially divided into intraoperative and postoperative systems. The intraoperative classification system considers its location, pattern, and stability of the fracture. The locations are divided into A, B, and C and correspond to the proximal metaphysis, diaphysis, and distal to stem, respectively. These fractures are further subdivided into fracture morphology and include cortical perforation, nondisplaced fracture, and displaced/unstable fracture. Duncan et al. postoperative Vancouver classification focuses on the stability of the prosthesis and quality of the surrounding bone.
Intraoperative Vancouver Classification
Postoperative Vancouver Classification
Immediate Treatment Options
Postoperative Periprosthetic Fractures
Intraoperative Periprosthetic Femur Fractures
Vancouver A1 and A2 fractures involve a cortical perforation and nondisplaced fracture of the proximal metaphysis, respectively. Vancouver A1 fractures are amenable to autograft bone graft from the acetabulum or femoral head and continuation of hip arthroplasty. Vancouver A2 fractures are fixed with a cerclage wire construct to prevent the fracture propagation and then insertion of the femoral component in standard fashion. Displaced A3 fractures may require provisional fixation with a plate or cerclage wire prior to placing a fully porous-coated stem. Vancouver B1 to B3 fractures involve the diaphysis. Lewallen et al. found that provisional fixation with cerclage wire is sufficient to stabilize the fracture and allow a fully porous-coated stem to be inserted distal to the fracture by a minimum of 2 to 3 cortices. Strut allografts may be necessary for B3 fractures. Vancouver C fractures are all distal to the femoral component. These fractures are similar to Vancouver B fractures and benefit from open reduction with internal fixation using a combination of plate and cerclage wiring and insertion of a long porous-coated femoral stem.
Before the radiographic evaluation, the differential diagnosis should include:
Drew et al. compared the mortality rate of periprosthetic proximal femur fractures and hip fractures. They reviewed 291 patients and found a one-year mortality rate of 24%, which is similar to the 30% cited for hip fractures. Zheng et al. highlighted the complexity of the surgery and its effect on morbidity and mortality; despite proper surgical treatment, patients struggle to recover entirely and often have unfavorable outcomes.
A periprosthetic proximal femur fracture is a challenging situation, and reports of complications are high. Lindahl et al. reported an 18% overall complication rate, with 23% of patients requiring reoperation. They found that 24% of patients resulted in a nonunion, and 24% suffered a refracture. In addition, they found that delayed union, failure of hardware, hip dislocation, neurovascular injury, wound complications, and infection also affects this patient population. Henderson et al. quoted the rate of infection for in-situ fixation with plating up to 9%. In-situ fixation with plate technology involves a more substantial operative dissection and trauma to the bone and soft tissue. Klein et al. reported a 21% rate of dislocation after revision THA due to the compromised abductor complex.
Revision arthroplasty with a diaphyseal fit stem provides a stable construct that has resulted in an overall decrease in patients requiring extensive weight-bearing restrictions. The goal of treatment is to adequately stabilize the fracture and return the patient to full weight-bearing as quickly as possible. Mulay et al. advocated for six to twelve weeks of weight-bearing restrictions for periprosthetic proximal femur fractures exclusively treated with plate fixation. They also included Vancouver B and C fractures into the same weight-bearing restriction as these fractures require operative fixation in addition to revision THA. The postoperative goal of Mulay et al. is toe-touch weight-bearing for six weeks with the progression to full weight-bearing by three months. Depending on the viability of abductors postoperative, patients may have a permanent Trendelenburg gait and rely on an assistive device such as a cane in the opposite hand. Postoperative patient immobilization drastically increases the complication risk associated with surgery, and avoidance of this limitation is one of the main indications for surgery.
Scheduled follow-up appointments in the aging population with their primary care physician should focus on fall prevention and promotion of bone health through exercise and medication. An emphasis on bony surveillance aims to avoid the dreaded complications of a fragility fracture. If a patient suffers a fragility fracture, they should be referred to a primary care or rheumatology physician to manage their bone health and develop a program to decrease the risk of future fractures.
The growing popularity of total hip arthroplasty procedures performed yearly has placed a burden on the surgeons, therapists, case managers, and nurses who are tasked with managing the perioperative course for patients who subsequently suffer a periprosthetic fracture. Effective management of these patients requires open communication with all levels of care. The primary goals of care include preoperative optimization, focused therapy, and an early transition of postoperative care to the outpatient setting. [Level 5]
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