A review of periprosthetic femoral fractures associated with total hip arthroplasty

Abstract

Periprosthetic fractures of the femur in association with total hip arthroplasty are increasingly common and often difficult to treat. Patients with periprosthetic fractures are typically elderly and frail and have osteoporosis. No clear consensus exists regarding the optimal management strategy because there is limited high-quality research. The Vancouver classification facilitates treatment decisions. In the presence of a stable prosthesis (type-B1 and -C fractures), most authors recommend surgical stabilization of the fracture with plates, strut grafts, or a combination thereof. In up to 20% of apparent Vancouver type-B1 fractures, the femoral stem is loose, which may explain the high failure rates associated with open reduction and internal fixation. Some authors recommend routine opening and dislocation of the hip to perform an intraoperative stem stability test to rule out a loose component. Advances in plating techniques and technology are improving the outcomes for these fractures. For fractures around a loose femoral prosthesis (types B2 and 3), revision using an extensively porous-coated uncemented long stem, with or without additional fracture fixation, appears to offer the most reliable outcome. Cement-in-cement revision using a long-stem prosthesis is feasible in elderly patients with a well-fixed cement mantle. It is essential to treat the osteoporosis to help fracture healing and to prevent further fractures. We provide an overview of the causes, classification, and management of periprosthetic femoral fractures around a total hip arthroplasty based on the current best available evidence.

Keywords: Vancouver type; femur; periprosthetic fracture; stem; total hip arthroplasty.

Figure 1.

Vancouver classification of postoperative periprosthetic femur fractures.

Figure 2.

Locking plate fixation for Vancouver type-C fractures around a well-fixed stem. Proximal fixation is achieved with screws below the prosthesis and unicortical screws angled around the prosthesis. A, The long condylar plate. B, Anteroposterior view of the outrigger device enabling screws to be placed around the stem of the prosthesis. C, Lateral view with 2 screws anteriorly and 2 screws posteriorly to the stem.

Figure 3.

Working length (WL) of a plate. Excessive use of screws close to the fracture site should be avoided because it creates excessive plate stiffness and high fracture strain, potentially leading to nonunion and plate fracture. (Modified with permission from Pletka et al, figure 1B.)

Figure 4.

Algorithm for the management of Vancouver type-B periprosthetic femur fractures. ORIF, open reduction and internal fixation; Intra-op, intraoperative; PFR, proximal femoral replacement.