JBJS | Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Periprosthetic Fracture of the Femur after Total Hip Arthroplasty. Treatment and Results to Date*†

The Journal of Bone & Joint Surgery, Volume 79, Issue 12

Instructional Course Lecture | December 01, 1997

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Periprosthetic Fracture of the Femur after Total Hip Arthroplasty. Treatment and Results to Date*†

DAVID G. LEWALLEN, M.D.‡; DANIEL J. BERRY, M.D.‡, ROCHESTER, MINNESOTA

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An Instructional Course Lecture, The American Academy of Orthopaedic Surgeons

The Journal of Bone & Joint Surgery. 1997; 79:1881-90

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Introduction

Postoperative periprosthetic femoral fractures have become increasingly common during the last decade. A wide range of problems, such as comminution and bone loss, are seen in association with these fractures, and the additional challenge of a loose femoral component is commonly encountered. When a femoral fracture occurs in a patient in whom the femoral component is in place, reconstruction may be reasonably straightforward or it may be nearly impossible. Options for treatment have included the use of traction, casts, and external braces; operative reduction with internal fixation; numerous revision procedures involving insertion of a long-stem femoral component for stabilization of the fracture; and bone-grafting with use of either autogenous grafts or allografts^{1-3,5-12,19-24,35,36,38-42,45,49-51,55,56}. These fractures must be treated according to their individual characteristics, the status of the implant, associated medical conditions, and the patient's level of physical activity^2,11,23,35. Knowledge of the results in previously reported series and information regarding the range of treatment options can facilitate optimum decision-making with regard to these injuries.

*Printed with permission of The American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 47, The American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March 1998.

†No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

‡Department of Orthopedics, Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905.

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Fig. 1 Graph showing the number of postoperative fractures of the femur after ipsilateral total hip arthroplasty at the Mayo Clinic during a twenty-five-year period beginning in 1971.

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Fig. 2 Bar graph showing the diagnoses that led to revision total hip arthroplasty at the Mayo Clinic between 1989 and 1993. Fracture was second only to loosening as a cause for revision, surpassing dislocation and infection.

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Fig. 3-A: Radiograph of a hip that had loosening of the implant, osteolysis, and pain seven years after a total hip arthroplasty. The patient was advised to have a revision but refused.

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Fig. 3-B: Three months later, after a misstep, the patient sustained a periprosthetic fracture through an osteolytic defect.

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Fig. 4-A Radiograph showing a periprosthetic fracture through an area of cortical perforation and extravasation of cement at the time of a revision total hip arthroplasty. Bone-grafting of any defects and avoidance of extravasation of cement can reduce the risk of fracture across this type of stress-riser.

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Fig. 4-B Treatment in the presence of a well fixed stem consisted of insertion of a plate with screws distally and cerclage bands proximally, with bone-grafting of the fracture line and the defect. The patient eventually had a solid union.

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Fig. 5 Intraoperative photograph showing onlay cortical strut allograft held with cerclage cables spanning a periprosthetic fracture.

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Fig. 6-A Radiograph of a hip with loosening, osteolysis, and a periprosthetic fracture that was neglected because of inadequate medical and radiographic follow-up.

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Fig. 6-B: Intraoperative photograph showing replacement of the damaged proximal aspect of the femur with a composite consisting of an allograft and a prosthesis. The procedure involved a step-cut osteotomy and cerclage wiring. The long stem of the femoral component spanned the site of the osteotomy.

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Fig. 6-C: The proximal femoral remnants and the trochanter were preserved and secured to the allograft to improve function and stability of the hip.

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Fig. 6-D Radiograph showing the final construct.

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Fig. 7 Photograph showing a modular proximal femoral replacement stem, which can be useful for the treatment of massive bone loss and a fracture of the proximal part of the femur. This implant is an alternative to the construct consisting of an allograft and a prosthesis, especially in an older patient.

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Fig. 8 Radiographs made after ill advised closed treatment, with traction, of a periprosthetic fracture associated with a loose stem. Malunion and painful loosening mandated an extensive revision procedure despite what was considered to be a successful union by the treating physician after prolonged immobilization.

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Fig. 9 Radiograph made after onlay strut-grafting and use of an extensively porous-coated stem. This procedure resulted in fracture-healing and a stable implant.

Prevalence of Postoperative Periprosthetic Femoral Fractures

The number of patients who are seen with a postoperative periprosthetic fracture of the femur has increased steadily at our institution during the last twenty-five years (Fig. 1). Between 1989 and 1993, fracture was the second leading cause of revision hip arthroplasty at the Mayo Clinic, ranking after loosening of the implant and before dislocation and infection (Fig. 2). Reports have suggested an over-all prevalence of between 0.1 and 1.1 per cent, with ten postoperative periprosthetic fractures (0.2 per cent) found in 5400 patients in one of the largest series. However, these estimates apply to patients who had a femoral component that was inserted with cement and include both primary and revision total hip arthroplasties^{1,18,30,31,49}. The time from the arthroplasty to the fracture ranged from six weeks to ten years in these reports. Lowenhielm et al., reporting on a series of 1442 primary hip arthroplasties performed with use of cement, calculated the cumulative postoperative risk of fracture to be 25.3 per 1000 at fifteen years³⁰. A survey of all records on total hip arthroplasties performed at the Mayo Clinic between 1969 and 1990, conducted with use of a computerized database from the Total Joint Registry, revealed a rate of femoral fracture of 0.6 per cent after 17,579 primary procedures performed with cement and a rate of 0.4 per cent after 2078 such procedures performed without cement during the same time-period. The rates were higher after revision procedures (2.8 per cent after 3265 procedures performed with cement compared with 1.5 per cent after 1132 procedures performed without cement).

One factor that has contributed to the increased prevalence of periprosthetic femoral fractures is the greater proportion of the population that is at risk. It has been twenty-eight years since total hip arthroplasty was introduced in the United States; more than 120,000 primary procedures are carried out each year, and this number is growing steadily³⁸. In contrast to patterns of practice in the 1970s and the early 1980s, the indications for the procedure now include younger patients, heavier patients, and those who have severe bone loss³⁸. Other factors that have contributed to the greater prevalence of these fractures include an increase in the number of patients having revision hip arthroplasty and an increase in the number having more than one such procedure. Many of these revisions are related to the cumulative effects of particles of debris in the joint, as periprosthetic osteolysis increases the risk of fracture (Figs. 3-A and 3-B)^23,42,44.

Treatment

Prevention of fractures of the femur following total hip arthroplasty is preferable to even the most successful treatment options. Preventive measures that have been recommended for use during the initial arthroplasty include avoiding the creation of cracks, defects, or windows in the bone intraoperatively and, if these stress-risers are present, bypassing them with a stem of sufficient length that they end two to three cortical diameters distal to the defect^{14,17,26,29,37,52}. Extravasation of cement out of the bone defects should be avoided as this can facilitate subsequent fracture through the unhealed stress-riser (Fig. 4-A)¹⁴. The use of cerclage wires for the fixation of periprosthetic cracks produced intraoperatively has been recommended to prevent propagation and a complete fracture^8,15,16,53. Bone-grafting of defects also is recommended to allow resolution of the stress-riser effect over time.

Regular radiographic follow-up of all patients who have had a total hip arthroplasty is essential for the detection of major osteolytic defects that may lead to a periprosthetic fracture as well as to failure and loosening of the implant^38,42. At our institution, all patients who have had an arthroplasty are followed with anteroposterior, lateral, and oblique radiographs at one, two, five, seven, and ten years postoperatively and every two to three years thereafter. Radiographs should be made more often if lysis develops or if other radiographic changes warrant increased surveillance. Many of the more challenging problems associated with periprosthetic fractures are due as much to inadequate radiographic follow-up as to the type of implant and the materials that were used. Revision is recommended before extensive bone loss and a resultant periprosthetic fracture have occurred, thereby obviating the need for more extensive operative treatment, which is associated with a greater risk of residual functional impairment. Periprosthetic fractures can be avoided only if regular radiographic follow-up is performed as recommended by the 1994 National Institutes of Health Consensus Conference on total hip replacement³⁸.

Options for the treatment of postoperative periprosthetic femoral fractures have included protection of the fracture¹²; traction^1,2,22,34,35; use of casts and braces³⁵; and internal fixation with use of cerclage wires or cables^2,35, screws with and without plates^2,35,50, and special plates that have claws, bands, or cerclage wires to allow fixation in the region of the intramedullary stem (Fig. 4-B)^{10,21,39,41,43,56}. Another option for treatment is revision of the femoral component, which is frequently necessary if the fracture occurs adjacent to a loose implant. These revisions have been performed with a stem inserted with cement; a long stem with proximal or extensive porous coating, inserted without cement; a composite consisting of an allograft and a prosthesis; a proximal femoral replacement stem; and a custom implant, stem sleeve, or extension^{1,2,11,20,23,24,33,44,45}. Each of these options for revision can be combined with cancellous bone-grafting or with strut allograft in the region of the fracture (Fig. 5)¹³. A construct consisting of an allograft and a prosthesis should be reserved for patients who have massive proximal femoral bone loss severe enough to preclude standard reconstruction (Figs. 6-A, 6-B, 6-C and 6-D)¹¹. In patients who have massive bone loss and a fracture, are more than seventy years of age, and place low demands on the hip, a modular proximal femoral replacement stem may be used (Fig. 7). The appropriate treatment for a patient must be determined on the basis of the availability of the materials needed for a particular method of reconstruction; the familiarity of the surgeon with the operative method; patient-related factors such as age, level of activity, bone quality, and configuration of the fracture; and the results that have been reported for the method under consideration^{2,11,25,27,28,35,46-48,54}.

Results of Treatment

Johansson et al., in 1981, reported on a series of twenty-three intraoperative and fourteen postoperative periprosthetic femoral fractures²². The fractures had been treated with various methods, including traction, internal fixation with cerclage wires and plates, revision with a long-stem implant, and resection arthroplasty. Of the fourteen postoperative fractures, eight were associated with complications. Only five of the arthroplasties that were followed by a postoperative fracture eventually yielded a satisfactory result²². Bethea et al., in a subsequent report, noted an association between postoperative fracture and previous procedures on the hip or a loose implant⁵. Of thirty-one hips that had a fracture four weeks to ten years after the arthroplasty, eighteen (58 per cent) had had at least two previous operations and twenty-three (74 per cent) had had loosening of the implant or osteolysis before the fracture. A number of methods were used for treatment; non-operative treatment yielded the poorest results, whereas a revision with use of a long-stem prosthesis yielded the best results.

Adolphson et al. reported the results of treatment of postoperative fracture in twenty-nine patients, twenty-one of whom had been managed with traction and eight of whom had been managed operatively¹. This report is important because it emphasizes the high rate of complications associated with traction. Of the twenty-one patients who had been managed with traction, six needed a subsequent operation because of malunion or malalignment, although all had healing of the original fracture. In contrast, three of the eight patients who had been managed operatively had a non-union¹.

Mont and Maar, in an effort to analyze the results in a larger number of patients, reviewed twenty-six articles that had been published between 1964 and 1991³⁵. The 487 patients described in those articles were stratified according to the location of the periprosthetic fracture and the type of treatment. These authors did not distinguish between patients according to the status of the fixation before the fracture, according to whether a revision had been done with or without cement, according to whether or not bone-grafting had been done, or according to the type of graft. The fractures were categorized into five types on the basis of location, with supracondylar fractures constituting a sixth type. The rates of satisfactory results varied among the different types of fractures and the different methods of treatment. The result of traction was satisfactory for 57 per cent of the forty-six fractures that were located along the length of the stem, 43 per cent of the fifty-eight that were at the tip of the stem, and 77 per cent of the seventy-seven that were just distal to the tip of the stem. Treatment with cerclage wires alone was less successful when it was used for fractures distal to the tip of the stem than when it was used for more proximal fractures around the stem. The use of plates and screws was satisfactory treatment for seven of fifteen fractures occurring along the length of the stem, twelve (48 per cent) of twenty-five at the tip of the stem, and twenty-eight (49 per cent) of fifty-seven distal to the tip of the stem³⁵.

Beals and Tower reported the results of treatment of ninety-three fractures in eighty-six patients who had had an arthroplasty performed by one of thirty different orthopaedic surgeons². Nine fractures failed to heal; therefore, the results of 102 interventions were reported. (One fracture needed to be treated three times.) The average time to the fracture was 4.7 years; 38 per cent of the patients had had a previous fracture of a type commonly associated with osteoporosis. The etiology could be determined for eighty-two fractures. Eighty-four per cent were due to a fall; 8 per cent, trauma; and 8 per cent, spontaneous fracture. Before the fracture, the original implant had been a well fixed cemented stem (45 per cent), a loose cemented stem (23 per cent), an ingrowth implant (25 per cent), or an Austin-Moore-type stem (7 per cent). Of the 102 operative interventions elected by the operating surgeon, 34 per cent consisted of implantation of an ingrowth femoral stem; 15 per cent, revision to a stem inserted with cement; and 23 per cent, internal fixation with use of plates, screws, or lag screws. The remaining 28 per cent of the interventions were non-operative. Despite the extremely small number of interventions that were non-operative, complications were common, with traction resulting in a 45 per cent rate of malunion or marked shortening of the femur and an 11 per cent rate of non-union. The use of lag screws alone resulted in a new fracture at the site of the screw or a non-union after a few procedures. Fifteen per cent of the 102 procedures involving plate fixation resulted in a new fracture and another two procedures, in failure of the fixation. A prosthesis was inserted with cement for revision in an additional 15 per cent of the 102 procedures and was associated with a 31 per cent rate of non-union and a 15 per cent rate of refracture. A prosthesis was inserted without cement for revision in 34 per cent of the procedures and was associated with the best results in the series; shortening was noted after 7 per cent of the procedures and a new fracture, after 7 per cent, but the implant subsided after 18 per cent of the procedures. To analyze the results of treatment, Beals and Tower used a system based on the fixation of the stem and the healing status of the fracture. An excellent result was defined as a stable implant and a healed fracture; a good result, as a stable stem with some subsidence and a healed fracture with mild or moderate deformity; and a poor result, as a loose stem, non-union, deep infection, a new fracture, or severe deformity. In this cumulative series, 32 per cent of the interventions led to an excellent result; 16 per cent, a good result; and 52 per cent, a poor result².

A recent review presented the results of revision total hip arthroplasty for the treatment of ninety-seven postoperative periprosthetic femoral fractures in ninety-four patients who had been managed from 1971 to 1993 at our institution. The average duration of follow-up was nearly five years (range, two to fourteen years); within two years, three implants had failed, three patients had died, and one patient had been lost to follow-up. The fractures were categorized with use of the Vancouver classification system¹¹, which defines trochanteric fractures as type A, fractures about the stem or the tip of the stem as type B, and fractures well distal to the tip as type C. Type-B fractures are further subdivided into those adjacent to a well fixed stem (type B1), those adjacent to a loose stem (type B2), and those associated with marked osseous deficiency or destruction around the implant (type B3)¹¹. Approximately 60 per cent of the fractures were type B2, and 25 per cent were type B3. Approximately 85 per cent of the fractures united, and 15 per cent did not. Stable long-term fixation of the stem was achieved in less than 50 per cent of the hips. Although more than 50 per cent of the hips had a loose femoral implant at the latest follow-up evaluation, more than 20 per cent had no pain or only minimum symptoms despite radiographic signs of subsidence or loosening. However, approximately 33 per cent had loosening and severe pain. Long-stem femoral components inserted with cement, proximally porous-coated long-stem components inserted without cement, and extensively porous-coated components inserted without cement all were used during the revision procedures. Insertion of a proximally porous-coated implant without cement was associated with the poorest results. An important observation was the development of a spontaneous fracture, in the absence of a fall or another inciting traumatic event, in more than 50 per cent of the patients who had a type-B3 fracture, in which bone loss and comminution are most severe; several of these patients had had no symptoms before the spontaneous fracture occurred. This finding reinforces the importance of regular radiographic follow-up after hip arthroplasty, in order to look for the massive bone loss characteristic of type-B3 fractures, which may be asymptomatic before catastrophic failure occurs.

Recommendations for Treatment

Of the available classification systems, we currently prefer the Vancouver system as it helps to guide treatment choices¹¹. The treatment of type-A fractures involving the greater or lesser trochanter depends on the underlying cause of the avulsion fracture. If the cause is severe periprosthetic osteolysis, then a revision is indicated to debride the osteolytic defects and to replace the component that is the source of the particles of debris, whereas simple avulsion of fragments of the greater or lesser trochanter in patients who have osteoporosis may be treated non-operatively in the presence of a well fixed stem. Type-B1 fractures, which, by definition, are associated with a well fixed stem, often can be treated with internal fixation. However, in patients who have a so-called first-generation implant and other problems related to the bearing surface or the position of the stem, revision may be preferable if it can be done without excessive bone damage. Type-C fractures (those well distal to a solidly fixed stem) are best treated with internal fixation unless they are minimally displaced and the position can be maintained with non-operative measures that do not require the patient to be recumbent for prolonged periods. All types of fractures associated with a loose femoral component are best treated with a revision, with possible rare exceptions dictated by unusual medical problems or advanced age. For all but the most debilitated patients, revision offers the best chance of achieving not only stable fixation and union of the fracture but also a functional hip and the highest over-all level of function for the patient (Fig. 8).

Several principles should be observed when a revision is performed for the treatment of a periprosthetic fracture. These include preservation of the bone stock whenever possible and achievement of stable fixation of the stem into intact host bone. This often necessitates distal fixation of the stem, which can be accomplished reliably with use of cement, with use of an extensively porous-coated stem, or with use of a stem that has grooves or slots if the diaphyseal bone segment is relatively intact. When cement is used, care should be taken to prevent it from interdigitating into the fracture fragments as this can inhibit union. We have found that monobloc, proximally porous-coated, distally smooth femoral stems have performed poorly in routine revision situations^4,32. This disappointing experience has also been borne out in association with fractures. However, it is important to note that none of these situations involved stems with trochanteric bolts or distal slots and grooves, which have been designed for the enhanced stability of proximally coated implants.

After a revision, cancellous bone-grafting of all fracture lines is recommended. Strut-grafting with cerclage wires is a reliable method for restoring osseous stability at the fracture site and for promoting union (Fig. 9). The use of a construct consisting of an allograft and a prosthesis or the use of a proximal femoral replacement stem should be reserved for hips with the most severe bone loss that cannot be reconstructed with standard methods. When either of these implants is used, it is helpful to preserve the proximal bone fragments and to wrap them around the component or the allograft, employing cerclage wires or cables in order to preserve the soft-tissue attachments, improve stability of the hip, and promote union. The use of a constrained acetabular insert or a bipolar articulation is reasonable when a proximal femoral replacement stem and a large allograft is used or when the presence of poor abductor and soft-tissue attachments proximally lead to concerns about stability.

In conclusion, periprosthetic femoral fractures can present a major reconstructive challenge, but a wide variety of treatment options are available. Classification of the fracture, with assessment not only of its location but also of the fixation of the stem and the quality of the bone, allows a rational choice of reconstructive options for the management of these patients.

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