Continuing Education Activity
Periprosthetic proximal femur fractures are complex orthopedic issues that carry significant morbidity and mortality. The demand for primary total hip arthroplasty is projected to grow to 572,000 procedures performed in 2030, a 174% increase from 2005. This activity reviews the evaluation and treatment of periprosthetic proximal femur fractures and reviews the role of the interprofessional team in improving care for patients with this condition.
Objectives:
Identify the etiology of periprosthetic proximal femur fractures.
Outline the appropriate evaluation of periprosthetic proximal femur fractures.
Review the management options available for periprosthetic proximal femur fractures.
Describe interprofessional team strategies for improving care coordination and communication to advance periprosthetic proximal femur fractures and improve outcomes.
Introduction
Total hip arthroplasty (THA) offers a reproducible alternative to individuals who have painful arthritis of the hip. The advancements in medicine have improved patient outcomes in arthroplasty and decreased hospital length of stay. Cooperation with the anesthesia department has revolutionized perioperative and postoperative pain management to limit narcotic use.[1] Interprofessional preoperative managementwith the primary care team seeks to optimize a patient before surgery or delay patients unfit for elective arthroplasty. Improvedpatient selection and widespread availability ofimplants have allowed primary total hiparthroplasty to be performed in patients of a wide age range and oftencompleted as an outpatient surgery. The desirefor primary total hip arthroplasty is predictedto risefrom 329,000 to 572,000 operationsin 2030, a 174% risefrom 2005.[2]A focus on individual health and preventative medicine combined with medical advancements, patients are surpassing previously established life expectancies.[3] The increasedutilizationin total hip arthroplasty has led to a concurrent increase in periprosthetic fractures.[4] Operative fixation of a periprosthetic fracture is taxing surgery that is best suited for surgeons with a significant volume of related procedures and understanding of the complexities of operative planning.
Etiology
Periprosthetic fractures have an increased prevalence in:
Female sex (hormonal imbalance)
Osteoporosis and osteopenia
Neuromuscular disease(e.g., Parkinson, epilepsy, ataxia)
Cognitive disorder (e.g. dementia)
Medication-related (chronic steroid use)
Inflammatory arthritides (e.g., rheumatoid arthritis, osteoarthritis, etc.)
Infection
Primary total hiparthroplasty (e.g.,aggressive broaching, stress shielding)
Implant specific (level of constraint, polyethylene wear)[2][5]
Epidemiology
The overall incidence of periprosthetic proximal femur fractures ranges from 0.1 to 18%. Revision arthroplasty, surgical technique, and implant type each can increase the incidence of fracture. Canton et al. found that revision total hip arthroplasty often requires extensive soft tissue and bony dissection and raises the incidence of periprosthetic fracture to 4 to 11%.[6] Kurtz et al. found that inadequate bone stock, overzealous femoral bone preparation, and mismatch between component and patients anatomy accounts for an intraoperative fracture risk of 1.7% for primary total hip arthroplasty (THA). Osteolysis, continuous bone loss, and stress shielding at the proximal femur raises the incidence of periprosthetic proximal femur fracture after primary THA at 20 years to 3.5%.[2]
Pathophysiology
Capone et al. found that intraoperative periprosthetic femur fractures account for 1.7% of primary and 12% of revision total hip arthroplasties.[7]Operative technique and surgical experience have a significant effect on the risk of intraoperative fracture.Abdelet al. found fourteen times increased rate of intraoperative fracture when a cementless femoral stem is used for primary THA.[8]They also foundthe risk of periprosthetic proximal femur fracture is associated with specific implant designs. A monoblock cup, elliptical cup, and metaphyseal fit femoral stem with extreme taper angles increase the risk of fracture.[8]
In the postoperative setting, minortrauma accounts for the majority of presentations of periprosthetic fractures. At-risk patients include those withosteoporosis, metabolic disease, medication-related bone loss, and substance abuse. Stress shielding of the proximal femur weakens the bone adjacent to an implant and creates a stress rise susceptible to fracture. The majority oftotal hipimplants are a combinationof a fewmetals, such as cobalt and chromium. Cuppone et al. evaluated the elastic modulus of cortical bone and that of a mixed metal arthroplasty component. Their study found the difference inelastic modulus from the surrounding cortical bone to be 7.7%that of the femoral component.[9]
History and Physical
A significant number ofpatients whopresent with periprosthetic fractures willsustain their injury performing activities of daily living and rarely report considerable trauma associated with their presentation. A thorough history of recent injuries oftenreveals a history of fragility fractures. Patient presentation is highly variable. Many patients present withintractable thigh or leg pain and an inability to ambulate, while some present to the office with vague thigh pain but still able to ambulate. The physicalexam varies between patients, but visible deformity is not easily recognizable secondary to the significant soft tissue surrounding the femur. Neurovascular injury is uncommon in these fractures but is evaluated and documented in every orthopedic patient.
Evaluation
The appropriate evaluation of a periprosthetic proximal femur fracture includes an x-ray assessmentof the extremity from hip to ankle. Adequate visualization of the ipsilateral hip and kneeis criticalfor determining what implants would be available to the performing surgeon. Thompson et al. stressed the importance of determining whether the implant has subsided from its position on primary arthroplasty.[10]Orthogonal imaging of the hipmay not always provide adequate imaging for preoperative planning. If warranted, a computed tomography (CT) scan may be orderedand has the benefit of fine detail with three-dimension reconstitution possible. Previous operative reports or familiarity with the radiographic appearance of standard arthroplasty implantsdramatically increases the ability to preoperative plan. The performing surgeon should be comfortable with a variety of surgical options ranging from in-situfixation, revision femoral arthroplasty, proximalfemoral replacement, and in rare situations, Girdlestone resection arthroplasty.
Classification systems play a significant role in orthopedics, and most fractures in the body have a classification systemdesigned to dictate treatment.[11]The Vancouver classification is a reliable and accurate tool that guides therapeutic plans. Naqvi et al. reviewed forty-five radiographs of patients with postoperative periprosthetic femur fractures and found an 81% interobserver agreement when classifying B1, B2, and B3 fractures.[12]The Vancouver classification was initially divided into intraoperative and postoperative systems. The intraoperative classification system considers its location, pattern, and stability of the fracture. The locations are divided into A, B, and C and correspond to the proximal metaphysis, diaphysis, and distal to stem, respectively. These fractures are further subdivided into fracture morphology and include cortical perforation, nondisplaced fracture, and displaced/unstable fracture. Duncan et al.postoperative Vancouver classification focus on the stability of the prosthesis and quality of the surrounding bone.[11]
Intraoperative Vancouver Classification
A = Proximal
A1 = Proximal metaphysis, cortical perforation
A2 = Proximal metaphysis, nondisplaced fracture
A3 = Proximal metaphysis, displaced, unstable fracture
B = Diaphyseal
B1 = Diaphyseal, cortical perforation
B2= Diaphyseal, nondisplaced fracture
B3 = Diaphyseal, displaced unstable fracture
C = Distal to stem
C1 = Distal to stem tip, cortical perforation
C2 = Distal to stem tip, nondisplaced fracture
C3 = Distal to stem tip, displaced unstable fracture
Postoperative Vancouver Classification
A = Fracture in the trochanteric region
AG = Fracture of the greater trochanter
AL = Fracture of the lesser trochanter
B = Fracture around the stem
B1 = Fracture around the stem or just below, well-fixed stem
B2 = Fracture around the stem or just below, a loose stem, with good proximal bone stock
B3 = Fracture around the stem or just below it with poor proximal bone stock
C = Fracture well distal to the tip of the prosthesis
Treatment / Management
Immediate Treatment Options
Risk of soft tissue compromise or neurovascular injury: emergent skeletalstabilization
Options: traction via placementof a traction pin or application of external fixator
Stable fracture with no soft tissue or neurovascular concern:
Immobilization, weight-bearing restrictions, skeletal immobilization (splint application, knee immobilizer).
Postoperative Periprosthetic Fractures
Nonoperative management
Indications: rare (medically unfit surgical candidates).
Restriction: non-weight bearing to involved extremity until callus present
Pearls: increase soft tissue surveillance in bed-bound patients (increase turns in bed, offload fracture with additional padding).
Education: crucial to educate patient and patient's family risk of complications (nonunion, malunion, skin compromise)
Vancouver A fractures (operative fixation):
Indications:Marsland et al. argue that displacement of the greater trochanter more than 2 cm significantly compromised the abductor complex and should be an indication for operative fixation.[13]
Fixation options:Ricci et al. described the use of trochanteric claw plates for additional fixation for displaced greater trochanter fractures.[14]
Pearls: a unique subset of fractures with a lack in the literature regarding the treatment of isolated Vancouver Ag fractures exist.
Postoperative weight-bearing: Ricci et al. recommendpartial weight-bearing with or without abduction brace for up to 3 months or until fracture callus is present.[13]
Other: If the greater trochanter is significantly stress shielded or damaged secondary to osteolysis, the fragment may not be amenable to stabilization with a plate and screw construct.
Vancouver B fractures (operative fixations):
Location: occur at or just distal to the tip of the femoral stem.
Vancouver B1 fractures
Stability: occur around a well-fixedprosthesis.
Bone stock: adequate bone stock surrounding the femoral implant.
Treatment:
Open reduction and internal fixation with a plate constructis the standard method of fixation.
Ricci et al. described the number of screws used in a locking plate proximal and distal depend on the location of the fracture. In general, four cortices proximal and eight cortices distal provide sufficient fixation.
Augmentation with cerclage wiring and allograft or autograft struts may be indicated in a very proximal or distallocation, existing intramedullary hardware, or adequatebone stock.[15]
If a stemmed total knee component is close to the proximal femoral component, overlapping the plate over the femoral prosthesislessensthe stressriserbetween the components.[14]
Postoperative care: non-weight bearing on operative extremity until fracture callus is present
Complications:
Fredin et al. found that immobilization and weight-bearing restrictions pose a significant medical concern for this patient population increased the length of hospital stay an average of 91 days.[16]
Lindahl et al. found a high rate of failure when open reduction with internal fixation was performed alone, citing a 34% failure rate attributed to a misdiagnosed loose femoral component (missed Vancouver B2 type fracture).[17]
Must compare theimmediate postoperative image of primary THA with preoperative X-rays taken in the emergency roomprior to fixation.
Vancouver B2 fractures
Stability: unstablefemoral component.
Bone stock: adequateproximal bone stock
Treatment:
Revision THA with a fracture bypassing diaphyseal fit stem and open reduction with internal fixation of the fracture is the recommended treatment for Vancouver B2 fractures.
Lewallen et al. describe the use of cerclage wire fixation distal to the fracture to prevent thepropagation of the fracture when reaming or broaching for therevision stem. Additional fixation is utilized proximal and distal to the fracture site to maintain fracture reduction.[18]The length of the stem should bypass the fracture by 2 to 3 cortical diameters to achieve sufficient distal fixation.[18]
Postoperative care:
Mulay et al. recommend thepatients to be restricted totoe-touch weight-bearing for six weeks on the postoperative extremity with progression to full weight-bearing by three months.[19]
Vancouver B3 fractures
Stability: Unstablefemoral component.
Bone stock:Adequate proximal bone stock
Treatment:
Options: revision THA with a diaphyseal fit prosthesis,tumor (mega) prostheses, and allograft prosthesis
Proximal fixation of the fracture with plate fixation with or without cerclage wire construct.[13]
Rayan et al.found that fully coated uncemented femoral stems have an excellent clinical outcomewith a union rate of 86 to 100%.[20]
Vancouver C fractures
Location: occur distal to the femoral prosthesis.
Stability: stable femoral component.
Bone stock: adequate proximal bone stock
Treatment:
Open reduction with internal fixation using locked, nonlocked, or compression plate technology with or without cerclage wire fixation.
O'Toole et al. highlighted the importance of plate length.They recommended the plate length should be long enough to overlap the distal aspect of the femoral prosthesis and amenable to four to six cortices distal. Unicortical screws at the level of the femoral stem offer additional support and can be combined with cerclage wire fixation if needed.[21]
Intraoperative Periprosthetic Femur Fractures
Vancouver A1 and A2 fractures involve a cortical perforation and nondisplaced fracture of the proximal metaphysis, respectively. Vancouver A1 fractures are amenable to autograft bone graft from the acetabulum or femoral head and continuation of hip arthroplasty. Vancouver A2 fractures are fixed with a cerclage wire construct to prevent the fracture propagation and then insertion of the femoral component in a standard fashion. Displaced A3 fractures may require provisional fixation with a plate or cerclage wire prior to placing a fully porous-coated stem. Vancouver B1 to B3 fractures involve diaphysis. Lewallen et al. found that provisional fixation with cerclage wire is sufficient to stabilize the fracture and allow a fully porous-coated stem to be inserted distal to the fracture by a minimum of 2 to 3 cortices.[18]Strut allografts may be necessary for B3 fractures. Vancouver C fractures are all distal to the femoral component. These fractures are similar to Vancouver B fractures and benefit from open reduction with internal fixation using a combination of plate and cerclage wiring and insertion of a long porous-coated femoral stem.
Differential Diagnosis
Before the radiographic evaluation, the differential diagnosis should include:
Periprosthetic fracture
Aseptic loosening
Prosthetic joint infection
Ligamentous injury
Fracture of the metal or polyethylene implant
Contusion
Hip dislocation
Venous thromboembolism
Occult fracture
Metallosis
Prognosis
Drew et al. compared the mortality rate of periprosthetic proximalfemur fractures and hip fractures. They reviewed 291 patients and found a one-year mortality rate of 24%, which is similar to the 30% cited for hip fractures.[22]Zheng et al. highlighted the complexity of the surgery and its effect on morbidity and mortality; despite proper surgical treatment, patients struggle to recover entirely and often have unfavorable outcomes.[23]
Complications
A periprosthetic proximal femur fracture is a challenging situation, and reports of complications are high. Lindahl et al. reported an 18% overall complication rate, with 23% of patients requiring reoperation. They found that 24% of patients resulted in anonunion, and 24% suffered a refracture.[17]In addition, they found thatdelayed union, failure of hardware, hip dislocation, neurovascular injury, wound complications, and infection alsoaffects this patient population.[17]Henderson et al. quoted the rate of infection for in-situ fixation with plating up to9%.[24] In-situ fixation with plate technology involves a more substantial operative dissection and trauma to the bone and soft tissue. Klein et al. reported a 21% rate of dislocation after revision THA due to the compromised abductor complex.[25]
Postoperative and Rehabilitation Care
Revision arthroplasty with a diaphyseal fit stem providesa stable construct that has resulted inan overall decrease in patients requiring extensive weight-bearing restrictions. The goal of treatment is to adequately stabilize the fracture and return the patient to full weight-bearing as quickly as possible.Mulay et al. advocated for six to twelve weeks of weight-bearing restrictions for periprosthetic proximalfemur fractures exclusively treated with plate fixation.[19] They also included Vancouver B and C fractures into the same weight-bearing restriction as these fractures require operativefixation in addition torevision THA. The postoperative goal ofMulay et al. istoe-touch weight-bearing for six weeks with the progression to full weight-bearing by three months.[19]Dependingon the viability of abductors postoperative, patients may have a permanent Trendelenburg gait and rely on an assistive device such as a cane in the opposite hand. Postoperative patient immobilizationdrastically increases the complication risk associated with surgery, and avoidance of this limitation is one of the main indications for surgery.
Deterrence and Patient Education
Scheduled follow-up appointments in the aging population with their primary care physician should focus on fall prevention and promotion of bone health through exercise and medication. An emphasis on bony surveillance aims to avoid the dreaded complications of a fragility fracture. If a patient suffers a fragility fracture, they should be referred to a primary care or rheumatology physician to manage their bone health and develop a program to decrease the risk of future fractures.
Enhancing Healthcare Team Outcomes
The growing popularityof total hip arthroplasty procedures performed yearly has placed a burden on the surgeons, therapists, case managers, and nurses who are tasked with managing the perioperative course for patients who subsequentlysuffer aperiprosthetic fracture. Care is enhanced by the use of this interprofessional team. Effective management of these patients requires open communication with all levels of care. The primary goals of care include preoperative optimization, focused therapy, and an early transition of postoperative care to the outpatient setting. [Level 5]
References
- 1.
Derogatis MJ, Sodhi N, Anis HK, Ehiorobo JO, Bhave A, Mont MA. Pain Management Strategies To Reduce Opioid Use Following Total Knee Arthroplasty. Surg Technol Int. 2019 Nov 10;35:301-310. [PubMed: 31237342]
- 2.
Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007 Apr;89(4):780-5. [PubMed: 17403800]
- 3.
Brown GC. Living too long: the current focus of medical research on increasing the quantity, rather than the quality, of life is damaging our health and harming the economy. EMBO Rep. 2015 Feb;16(2):137-41. [PMC free article: PMC4328740] [PubMed: 25525070]
- 4.
Canton G, Fazzari F, Fattori R, Ratti C, Murena L. Post-operative periprosthetic humeral fractures after reverse shoulder arthroplasty: a review of the literature. Acta Biomed. 2019 Dec 05;90(12-S):8-13. [PMC free article: PMC7233712] [PubMed: 31821278]
- 5.
Lombardo DJ, Siljander MP, Sobh A, Moore DD, Karadsheh MS. Periprosthetic fractures about total knee arthroplasty. Musculoskelet Surg. 2020 Aug;104(2):135-143. [PubMed: 31643045]
- 6.
Canton G, Ratti C, Fattori R, Hoxhaj B, Murena L. Periprosthetic knee fractures. A review of epidemiology, risk factors, diagnosis, management and outcome. Acta Biomed. 2017 Jun 07;88(2S):118-128. [PMC free article: PMC6179004] [PubMed: 28657573]
- 7.
Capone A, Congia S, Civinini R, Marongiu G. Periprosthetic fractures: epidemiology and current treatment. Clin Cases Miner Bone Metab. 2017 May-Aug;14(2):189-196. [PMC free article: PMC5726208] [PubMed: 29263732]
- 8.
Abdel MP, Watts CD, Houdek MT, Lewallen DG, Berry DJ. Epidemiology of periprosthetic fracture of the femur in 32644 primary total hip arthroplasties: a 40-year experience. Bone Joint J. 2016 Apr;98-B(4):461-7. [PubMed: 27037427]
- 9.
Cuppone M, Seedhom BB, Berry E, Ostell AE. The longitudinal Young's modulus of cortical bone in the midshaft of human femur and its correlation with CT scanning data. Calcif Tissue Int. 2004 Mar;74(3):302-9. [PubMed: 14517712]
- 10.
Thompson SM, Lindisfarne EA, Bradley N, Solan M. Periprosthetic supracondylar femoral fractures above a total knee replacement: compatibility guide for fixation with a retrograde intramedullary nail. J Arthroplasty. 2014 Aug;29(8):1639-41. [PubMed: 24929282]
- 11.
Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr Course Lect. 1995;44:293-304. [PubMed: 7797866]
- 12.
Naqvi GA, Baig SA, Awan N. Interobserver and intraobserver reliability and validity of the Vancouver classification system of periprosthetic femoral fractures after hip arthroplasty. J Arthroplasty. 2012 Jun;27(6):1047-50. [PubMed: 22425302]
- 13.
Marsland D, Mears SC. A review of periprosthetic femoral fractures associated with total hip arthroplasty. Geriatr Orthop Surg Rehabil. 2012 Sep;3(3):107-20. [PMC free article: PMC3598446] [PubMed: 23569704]
- 14.
Ricci WM, Borrelli J. Operative management of periprosthetic femur fractures in the elderly using biological fracture reduction and fixation techniques. Injury. 2007 Sep;38 Suppl 3:S53-8. [PubMed: 17723793]
- 15.
Ricci WM, Bolhofner BR, Loftus T, Cox C, Mitchell S, Borrelli J. Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant. Surgical Technique. J Bone Joint Surg Am. 2006 Sep;88 Suppl 1 Pt 2:275-82. [PubMed: 16951099]
- 16.
Fredin HO, Lindberg H, Carlsson AS. Femoral fracture following hip arthroplasty. Acta Orthop Scand. 1987 Feb;58(1):20-2. [PubMed: 3577736]
- 17.
Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register. J Arthroplasty. 2005 Oct;20(7):857-65. [PubMed: 16230235]
- 18.
Lewallen DG, Berry DJ. Periprosthetic fracture of the femur after total hip arthroplasty: treatment and results to date. Instr Course Lect. 1998;47:243-9. [PubMed: 9571425]
- 19.
Mulay S, Hassan T, Birtwistle S, Power R. Management of types B2 and B3 femoral periprosthetic fractures by a tapered, fluted, and distally fixed stem. J Arthroplasty. 2005 Sep;20(6):751-6. [PubMed: 16139712]
- 20.
Rayan F, Konan S, Haddad FS. Uncemented revision hip arthroplasty in B2 and B3 periprosthetic femoral fractures - A prospective analysis. Hip Int. 2010 Jan-Mar;20(1):38-42. [PubMed: 20235063]
- 21.
O'Toole RV, Gobezie R, Hwang R, Chandler AR, Smith RM, Estok DM, Vrahas MS. Low complication rate of LISS for femur fractures adjacent to stable hip or knee arthroplasty. Clin Orthop Relat Res. 2006 Sep;450:203-10. [PubMed: 16721350]
- 22.
Drew JM, Griffin WL, Odum SM, Van Doren B, Weston BT, Stryker LS. Survivorship After Periprosthetic Femur Fracture: Factors Affecting Outcome. J Arthroplasty. 2016 Jun;31(6):1283-1288. [PubMed: 26935943]
- 23.
Zheng L, Lee WY, Hwang DS, Kang C, Noh CK. Could Patient Undergwent Surgical Treatment for Periprosthetic Femoral Fracture after Hip Arthroplasty Return to Their Status before Trauma? Hip Pelvis. 2016 Jun;28(2):90-7. [PMC free article: PMC4972891] [PubMed: 27536650]
- 24.
Henderson CE, Lujan T, Bottlang M, Fitzpatrick DC, Madey SM, Marsh JL. Stabilization of distal femur fractures with intramedullary nails and locking plates: differences in callus formation. Iowa Orthop J. 2010;30:61-8. [PMC free article: PMC2958272] [PubMed: 21045973]
- 25.
Klein GR, Parvizi J, Rapuri V, Wolf CF, Hozack WJ, Sharkey PF, Purtill JJ. Proximal femoral replacement for the treatment of periprosthetic fractures. J Bone Joint Surg Am. 2005 Aug;87(8):1777-81. [PubMed: 16085618]
Disclosure: Dominic Marino declares no relevant financial relationships with ineligible companies.
Disclosure: Daniel Mesko declares no relevant financial relationships with ineligible companies.
