Outcomes of post-operative periprosthetic femur fracture around total hip arthroplasty: a review

Abstract

As the number of primary total hip arthroplasties increase over the next several decades so will the incidence of periprosthetic fractures around the femoral stem. Treatment can reliably be predicted using the Vancouver classification with internal fixation being indicated in fractures involving a stable implant and revision arthroplasty indicated in those with unstable prostheses. Non-displaced fractures involving the greater and lesser trochanter can generally be treated non-operatively. Extensively porous-coated stems and the use of modular uncemented revision stems to treat Vancouver B fractures have shown encouraging results. The treatment of Vancouver C periprosthetic fractures continues to follow basic AO fixation principles with an emphasis on eliminating stress risers with adequate implant overlap and length. This review will focus on the risk factors and classification of these fractures, as well as highlight the treatment options for post-operative periprosthetic femoral fractures around a total hip arthroplasty.

Keywords:

• hip
• periprosthetic fracture
• revision
• total hip arthroplasty
• Vancouver classification

Financial & competing interests disclosure

MA Mont receives royalties from Stryker; Wright Medical Technology, Inc; is a paid consultant for Biocomposites; DJ Orthopaedics; Janssen; Joint Active Systems; Medtronic; Sage Products, Inc.; Stryker; TissueGene; Wright Medical Technology, Inc.; has received research support from DJ Orthopaedics; Joint Active Systems; National Institutes of Health (NIAMS & NICHD); Sage Products, Inc.; Stryker; Tissue Gene; Wright Medical Technology, Inc.; is on the editorial/governing board of the American Journal of Orthopedics; Journal of Arthroplasty; Journal of Bone and Joint Surgery – American; Journal of Knee Surgery; Surgical Techniques International and is a board member for AAOS. BH Khadia is a paid consultant/speaker for Sage Products, Inc. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Early mobilization of patients will continue to be stressed along with adequate venous thromboembolic prophylaxis and proper use of perioperative antibiotics.

• Perhaps the most successful strategy will be the one made on a case-by-case basis based upon the fracture pattern, patient activity level and with which technique is the surgeon most comfortable.

• The incidence of periprosthetic femur fractures will continue to increase due to the expanding indications of patients who are receiving hip arthroplasty.

• Non-operative management in selected Vancouver A fractures continue to be successful.

• Determining the stability of an implant is critical in determining outcome (Vancouver B1 vs B2/B3). Intra-operative testing in equivocal cases is the only definitive method of determining prosthesis stability.

• There are several techniques and implants available to treat to Vancouver B fractures and these will continue to evolve with both implant design and surgical technique.

• Vancouver C fractures can be treated independent of the proximal stem with the goal of implant overlap to minimize stress-risers.