Revision total hip arthroplasty for periprosthetic fracture: epidemiology, outcomes, and factors associated with success

Abstract

The aging population and the increasing number of patients with primary total hip arthroplasties (THA) has equated to an increased incidence of periprosthetic fractures (PPF) of the hip. These injuries are a significant source of patient morbidity and mortality, placing a financial burden on healthcare systems worldwide. As the volume of PPF is expected to along with the growing volume of primary and revision THA, it is important to understand the outcomes and factors associated with treatment success. The choice of procedure is in large part guided by the help of the Vancouver Classification system, which is a valid and reproducible system that classifies fractures based on several factors including site of fracture, implant stability and bone stock. PPFs account for approximately 18% of revision THA (rTHA) procedures. rTHA for PPFs is commonly indicated in Vancouver B2 and B3 fractures, to bypass a lack of metaphyseal support with diaphyseal fixation. Such revisions are technically challenging and typically require urgent treatment, with inherent difficulties in patient optimization, leading to a notable rate of post-operative complications, re-revision and mortality. This article reviews epidemiology, health economics and risk factors for PPFs. It additionally reviews outcomes associated with rTHA for PPFs including peri-operative complications, indications for re-operation, rates of re-operation and rates of mortality. Finally, it aims to identify evidence-based factors that have been associated with successful management including modifiable patient-related factors, uncemented vs. cemented stems, stem design (porous coated stems vs. fluted tapered stems), modularity, dislocation and its impact on outcomes following rTHA and strategies for managing bone loss.

Keywords: Hip; periprosthetic hip fracture; revision total hip arthroplasty (rTHA); trauma.

Figure 1

Management of a PPF around a cemented femoral implant. (A) Example of patient with left sided Vancouver B2 peri-prosthetic fracture around a cemented femoral stem; (B) during rTHA, the cement mantle was removed and revision to a long-stemmed cementless Arcos femoral component was performed, with cementation of a liner and addition of 2 wires for fixation. PPF, periprosthetic fractures; rTHA, revision total hip arthroplasty.

Figure 2

rTHA for Vancouver B2 and B3 PPFs with a fluted tapered stem. (A) Example of Vancouver B2 peri-prosthetic fracture from index primary THA; (B) treated with rTHA with Arcos modular fluted, tapered stem, and ORIF with 3 Dall Miles Cables. rTHA, revision total hip arthroplasty; PPF, periprosthetic fractures; ORIF, open reduction internal fixation.

Figure 3

Management of instability following rTHA for PPFs. (A) An example of a Vancouver B2 PPF; (B) treated with rTHA with Stryker Modular Restoration Stem and supplemental fixation with Accord trochanteric fixation plate and multiple cerclage cables; (C) post-operative posterosuperior dislocation of the femoral head from the acetabular component; (D) dislocated rTHA treated with rTHA to Medacta Dual Mobility Acetabular Cup with Medacta Versafit dual mobility polyethylene liner. PPFs, periprosthetic fractures; rTHA, revision total hip arthroplasty.