Periprosthetic fractures around a cementless hydroxyapatite-coated implant: a new fracture pattern is described

Abstract

Background: Periprosthetic fractures can occur both intraoperatively and postoperatively with implantation of cementless tapered stems.

Questions/purposes: In a large cohort of patients receiving cementless, proximally hydroxyapatite-coated femoral implants, we answered the following questions: What was the incidence of intraoperative and postoperative fractures associated with the implant? What were the fracture patterns as classified by the Vancouver classification system? Did the Vancouver classification represent the fracture patterns found? How were the fractures treated and what were the treatment outcomes; that is, how many fractures healed and did the stems osseointegrate?

Methods: We evaluated 1039 hips (932 patients) from three prospective studies. The hips were divided into three groups: no fractures, intraoperative fractures, and postoperative fractures. Demographic differences among the groups were noted. Postoperative fractures were classified using the Vancouver classification system. We judged stem stability using Engh's criteria and fracture union was determined by the treating surgeon and confirmed by the authors.

Results: We identified 58 periprosthetic fractures in the 1039 hips (5.6%): 38 intraoperative (3.7%) and 20 postoperative (1.9%). Eleven of the postoperative fractures were classifiable by the original Vancouver classification system and nine were of the newly described "clamshell" variety, not classifiable by this system. No intraoperative fractures extended below the lesser trochanter. Twenty-five of these fractures were treated with a single cable or cerclage wire. The remaining received no specific treatment. Of the 20 postoperative fractures, five were treated nonoperatively. All stems osseointegrated.

Conclusions: Both intraoperative and postoperative fractures can be managed with success when the stem is stabilized or found to be osseointegrated. An adjustment to the Vancouver classification is suggested to include the clamshell fracture, which has not been previously described.

Fig. 1

A radiograph shows the clamshell (pseudo A_TL or new B₂) fracture.

Fig. 2

A proposed modification of the Vancouver classification is shown, now including the clamshell fracture. For definitions of the fracture types, see Table 3.