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2000

C OPYRIGHT Ó 2008 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Current Concepts Review


Intraoperative Periprosthetic Fractures
During Total Hip Arthroplasty
Evaluation and Management
By Darin Davidson, MD, MHSc, Jeffrey Pike, MD, Donald Garbuz, MD, MHSc, FRCSC,
Clive P. Duncan, MB, MSc, FRCSC, and Bassam A. Masri, MD, FRCSC

ä Intraoperative periprosthetic fractures are becoming more common given the increased prevalence of revision
total hip arthroplasty and increased use of cementless fixation.

ä Risk factors for intraoperative periprosthetic fractures include the use of minimally invasive techniques; the use of
press-fit cementless stems; revision operations, especially when a long cementless stem is used or when a short
stem with impaction allografting is used; female sex; metabolic bone disease; bone diseases leading to altered
morphology such as Paget disease; and technical errors at the time of the operation.

ä Appropriate treatment of intraoperative periprosthetic fractures does not compromise the long-term results of total
hip arthroplasty unless the bone damage precludes stable fixation of the implant.

Total hip arthroplasty is a highly successful procedure with a hip arthroplasty. In one study, an intraoperative femoral
high likelihood of excellent long-term results and a relatively fracture was encountered during 1% (238) of 23,980 primary
low risk of complications. One of the major complications of total hip arthroplasties compared with 7.8% (497) of 6349
total hip arthroplasty is periprosthetic fracture. Although both revisions2, and subsequent studies have demonstrated similar
postoperative and intraoperative fractures occur, it is the for- results13,21-24. In the study mentioned above2, the rate of peri-
mer that have received the greatest attention in the literature. prosthetic fracture during primary total hip arthroplasty was
Despite this, the prevalence of intraoperative periprosthetic 5.4% (170 of 3121) when a cementless femoral component was
fractures is increasing1-16. It is imperative that the modern re- used compared with 0.3% (sixty-eight of 20,859) when a ce-
constructive hip surgeon be familiar with the classification and mented stem was used. Other studies demonstrated a preva-
treatment of these complications. Only intraoperative fractures lence of intraoperative fracture of 1.2% (seven of 605) when a
will be considered in this review. cemented stem was used and 3% (thirty-nine of 1318) when a
cementless femoral component was used15,24. The variability in
Intraoperative Femoral Fractures the reported prevalences of periprosthetic fractures may reflect
Epidemiology and Etiology differences between studies with regard to sample size or the use
Intraoperative periprosthetic femoral fractures have received of different femoral stems and insertion techniques. Sarvilinna
greater attention in the literature than have acetabular fractures, et al.23 reported an odds ratio of 0.6 (95% confidence interval,
possibly because of the difficulty in identifying intraoperative 0.2 to 1.9) for the occurrence of a fracture in association with
acetabular fractures at the time of the operation17-20. The risk of use of a cementless femoral stem compared with use of a ce-
an intraoperative femoral fracture has been shown to be mented stem in a small case-control study that predominantly
greatest when a cementless component is used in revision total included postoperative fractures. These results must be in-

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a
member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial
entity. Commercial entities (Zimmer and Stryker) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research
fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his
or her immediate family, is affiliated or associated.

J Bone Joint Surg Am. 2008;90:2000-12 d doi:10.2106/JBJS.H.00331


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terpreted with caution since there was substantial variability eighty-three fractures occurred. The only significant risk fac-
surrounding the estimate of the odds ratio. The prevalence of tors were female sex, use of an uncemented femoral stem,
intraoperative fractures is increased in the revision setting. In previous surgery on the affected hip, and revision total hip
one series of 175 cementless revision procedures, the reported arthroplasty (p < 0.05). The authors did not utilize a logistic
fracture rate was 19% (thirty-four of 175)25. In another study, regression analysis to determine the risk; consequently, the
the prevalence of intraoperative fractures in association with magnitude of the risk and the possible confounding effects of
uncemented stems in the revision setting was reported to be those variables are unknown.
20.9% (322 of 1536) compared with only 3% (thirty-nine of Several patient characteristics may be associated with an
1318) in association with cemented stems2. increased risk of intraoperative fracture. Female sex and in-
Lerch et al.26 reported a case-control study in which creased age have been suggested to be independent risk factors5;
forty-two patients with an intraoperative femoral fracture were however, these factors may be confounded by osteoporosis.
compared with forty-two controls who did not have a fracture. Medical comorbidities, in particular rheumatoid arthritis, have
All fractures occurred in association with uncemented stems. been suggested to be risk factors, but they may be similarly
Forty of the forty-two fractures united, and there were two in- confounded by associated osteopenia9,10. Altered bone mor-
stances of nonunion of a fracture in the greater trochanter with phology or deformity, as seen in Paget disease13, can also in-
trochanteric migration. There were no differences in the Harris crease the risk of fracture.
hip scores, Short Form-36 (SF-36) scores, or postoperative There is a multifactorial impact on the risk of intra-
complications between the two groups. operative femoral fracture in the setting of revision total hip
arthroplasty. The increasing number of revision procedures in
Risk Factors older patients introduces the effect of osteopenia, osteolysis, or
The risk factors for intraoperative femoral fractures have been stress-shielding with subsequent bone defects as well as the
more widely reported than have those for acetabular fractures. presence of stress-risers related to previous procedures. Un-
There is an increased risk in association with cementless stems, derreaming of the femoral cortex, use of a large-diameter
especially in the revision setting. This is predominantly due to femoral stem, and a low ratio between the diameters of the
the need for press-fitting of cementless stems in conjunction femoral cortex and canal have been associated with a greater risk
with the bone loss typically associated with revision total hip of intraoperative fracture37.
arthroplasty. The potential mismatch between the bow of the
femur and the bow of the stem is accentuated by the use of a long Diagnosis
revision stem, increasing the risk of intraoperative fracture. The surgeon must have a high index of suspicion for iatrogenic
Issack et al.27 reported an intraoperative fracture during four- fractures. During insertion of the stem, particularly an un-
teen (8%) of 175 cementless revision total hip arthroplasties in cemented component, a sudden change in resistance is highly
which a porous-coated, distally slotted, fluted stem was used. suggestive of a femoral fracture. Intraoperative radiographs
Other techniques used in revision total hip arthroplasty, in should be made to rule out fracture when a concern is raised. It
particular impaction bone-grafting, may increase the risk of should be noted that a nondisplaced fracture may not be visu-
fracture. Use of prophylactic cerclage wiring, longer stems, and alized on radiographs, emphasizing the need to combine in-
possibly cortical onlay allografts11,13 should be considered in traoperative clinical assessment with the imaging findings in
conjunction with this technique. The prevalence of intraop- order to diagnose all fractures. The stability of the component,
erative femoral fracture during impaction bone-grafting has particularly an uncemented stem, must be ensured prior to
been reported to be between 4% (three of sixty-eight) and 32% closure.
(twenty-two of sixty-eight)28-34. Farfalli et al.34 reported a series
of fifty-nine intraoperative fractures that had occurred during Classification
revision total hip arthroplasty with impaction bone-grafting. It has been recommended that treatment of both intraoperative
There were thirty-four frank fractures (58%) and twenty-five and postoperative fractures be based on the classification of the
instances of cortical perforation (42%). The majority of the injury11,38. The Vancouver classification for intraoperative
fractures (44%) occurred during cement removal, while seven fractures (Fig. 1) can be used to guide management11,39, al-
fractures (12%) occurred during allograft impaction and though, in contrast to the Vancouver classification system for
twenty-six (44%) were diagnosed in the immediate postop- postoperative fractures, its reliability and validity have not been
erative period. tested40. The intraoperative classification takes into account the
The impact of minimally invasive techniques was studied location, pattern, and stability of the fracture. Intraoperative
by Asayama et al.35, who reported an intraoperative fracture in fractures are classified as type A if they involve the proximal
two of fifty-two patients treated with a limited-incision direct metaphysis, type B if the fracture is diaphyseal, and type C if
lateral approach for a primary total hip arthroplasty. There the fracture is distal to the stem tip and not amenable to in-
were no fractures in patients treated with a standard incision, sertion of the longest revision stem. Each type is further sub-
defined as one >10 cm in length. Moroni et al.36 investigated classified as subtype 1 if there is only a cortical perforation,
risk factors for intraoperative femoral fractures in a retro- subtype 2 if there is a nondisplaced crack, and subtype 3 if
spective study of 3566 total hip arthroplasties, during which there is a displaced unstable fracture pattern.
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Fig. 1
Vancouver classification of intraoperative femoral periprosthetic fractures. A: type A1; B: type A2; C: type A3; D: type B1; E: type B2; F: type B3; and
G: type C1 (left image), type C2 (center image), and type C3 (right image). (Reprinted, with permission, from: Greidanus NV, Mitchell PA, Masri BA,
Garbuz DS, Duncan CP. Principles of management and results of treating the fractured femur during and after total hip arthroplasty. Instr Course
Lect. 2003;52:309-22.)

Treatment and Results procedure that does not compromise, and possible improves,
Accurate classification of the fracture type allows appropriate outcomes. The implant is usually stable with this construct.
management11,39. We are not aware of any comparative studies If a fully porous-coated stem is used, the fracture may be ig-
providing evidence regarding the ideal treatment of these var- nored as long as there is no distal propagation of the fracture
ious fracture types. The principles of treatment include en- line. Type-A3 fractures can be treated with a porous-coated
suring stability of the total hip arthroplasty components and the diaphysis-fitting stem or a tapered-fluted stem. The above two
fracture, avoidance of fracture propagation, and maintenance recommendations are based on our experience and on basic
of component position and alignment. Adherence to these biomechanical principles. An isolated fracture of the greater
principles should provide the greatest chance for good long- trochanter can be treated with trochanteric fixation with wires,
term outcomes, and these principles are likely to remain con- cables, or a claw-plate (Fig. 2) in order to reduce and stabilize
stant regardless of changes in technology or surgical techniques. the fracture, in keeping with basic orthopaedic principles.
In our experience, type-A1 fractures have usually been These fractures do not preclude the use of cement, but care
stable and can be treated with bone graft alone, usually obtained must be taken to occlude breaches in the cortex to achieve an
from the acetabular reaming. We prefer to treat type-A2 frac- effective cement mantle during pressurization, to protect im-
tures with placement of cerclage wire before the stem is inserted portant neurovascular structures from injury due to extruded
to prevent propagation if a proximally coated stem is used. cement, and to ensure that there is no cement between the
While there is no solid evidence for this recommendation, it fracture fragments.
makes sense to stabilize these fractures, particularly because the Type-B1 fractures usually occur during cement removal
addition of cerclage wire adds very little morbidity and is a rapid and can be treated by bypassing the affected area by two cor-
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The reported results of treatment of intraoperative fem-


oral fractures19,21,27 are difficult to compare because different
fixation strategies have been used; there have been no com-
parative studies, to our knowledge; and there has been a lack of
consistency in the classification of the fractures.
Early reports described various methods of treatment for
intraoperative fractures24,42. Khan and O’Driscoll42 reported on
seventeen fractures, with the short oblique fractures treated
with a standard femoral implant, the long oblique fractures
treated with open reduction and internal fixation, and the
fractures distal to the stem tip treated with skeletal traction.
This third method, although thought appropriate at the time
of the study, would not be recommended currently, illustrating
the difficulty in the interpretation of the literature.
Farfalli et al.34 utilized cerclage wires for all vertical per-
forations, metaphyseal fractures, and trochanteric fractures.
Patients younger than sixty-five years of age were treated with
placement of a cortical allograft with impacted bone graft and
a cemented short femoral stem. If a cemented stem is used,
great care must be taken to ensure that there is no cement
within the fracture lines because of the associated increased
risk of nonunion. The preference at our center is to bypass the
fracture with a cementless diaphysis-fitting stem and to aug-
ment the fixation with cerclage wiring and possibly a cortical
Fig. 2 allograft. These treatment options have not, however, been
The trochanteric claw-plate (Zimmer), which can be evaluated in a comparative study, to our knowledge. Chappell
used for fixation of greater trochanteric and Lachiewicz43 described fifty-four consecutive cementless
fractures. revision total hip arthroplasties associated with a total of nine
femoral fractures. Eight of those fractures occurred during
tical diameters with a longer stem; this magnitude of bypass insertion of a curved stem and one, during exposure of the
has been shown to provide sufficient stability41. Allograft femur. The fractures were treated with cortical allografts and
cortical struts can be used to supplement fixation. Type-B2 protected weight-bearing, with a successful result in six cases.
fractures usually result from increased hoop stress during Berend et al.44 reported on 1320 primary total hip arthro-
placement of either the broach or the implant. These injuries plasties done with use of an uncemented femoral stem. There
may be missed intraoperatively, in which case they are usually were fifty-eight intraoperative calcar fractures, which were
diagnosed on postoperative radiographs. If they are diagnosed treated with cerclage wires or cables and unrestricted weight-
intraoperatively, management can consist of placement of bearing postoperatively. At the time of follow-up, at a mean of
cerclage wire as long as the implant is stable (Fig. 3). If implant 7.5 years and a minimum of two years, no patient had un-
stability has been compromised, one should consider bypass- dergone a revision.
ing the defect, if possible. Cortical allograft may be used if the There have been few recent investigations of modern
bone quality is deemed to be poor or if the fracture cannot be treatment techniques for intraoperative fractures. Paprosky and
bypassed with the stem. If these injuries are diagnosed post- Aribindi45 described one intraoperative fracture among eighty-
operatively, treatment should consist of protected weight- seven patients treated with an extensively porous-coated,
bearing and close observation. Type-B3 injuries usually occur bowed, cementless revision stem with a bullet tip (Solution;
during hip dislocation, cement removal, or final stem inser- DePuy, Warsaw, Indiana); a longer curved stem was used to
tion. These fractures can be treated by bypassing the fracture bypass the fracture. Duwelius et al.4 reported two intraoperative
site with a longer stem and using cortical allograft if necessary fractures that had propagated distal to the lesser trochanter and
(Figs. 4-A and 4-B). were treated with two cerclage wires with no complications.
Type-C1 fractures usually occur during cement removal To our knowledge, the largest study of intraoperative
or canal preparation and can be treated with morselized bone femoral fractures at the time of revision total hip arthroplasty
graft and by bypassing the fracture site as well as use of cortical was reported by Meek et al.37. Of 211 consecutive patients,
onlay allografts. Treatment of type-C2 fractures can consist of sixty-four (30%) sustained an intraoperative femoral fracture
use of cerclage wires and augmentation with an allograft cortical and 147 did not sustain a fracture. An extensively coated
strut (Figs. 5-A and 5-B), whereas type-C3 fractures can be femoral stem for which a diaphyseal fit had been obtained had
treated with open reduction and internal fixation (Figs. 6-A, been used in all patients. The fractures were classified with use
6-B, and 6-C). of the Vancouver system11,39, and the most prevalent type was
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Fig. 3
Treatment of a type-B2 fracture with cerclage wire fixation.

B2 (observed in thirty-nine cases [61%]) followed by B1 Biomechanical studies have been performed to compare
(observed in eleven [17%]). The risk factors for intraoperative the strengths of different fixation constructs. Schmotzer et al.46
fracture were substantial bone loss, a low ratio between the studied several different constructs and reported that cables
cortical and canal diameters, underreaming of the femoral were stronger than cerclage wires; dynamic plates were better
canal, and use of a large-diameter stem. A wide variety of than Ogden plates; and, for the treatment of unstable fractures,
treatment modalities were used, with the most common being revision with a long cementless stem should be supplemented
cerclage wire fixation (in twenty-five cases [39%]) followed by with allograft cortical struts. Another biomechanical study
placement of an allograft cortical strut (in eighteen [28%]). At demonstrated that plate constructs with only screws or screws
a minimum of two years postoperatively, there was no difference combined with cables provided the greatest fixation stability47.
in the functional outcome according to the Western Ontario and Use of double plates (one anterior and one lateral) has been
McMaster Universities Osteoarthritis Index (WOMAC) or the demonstrated to provide greater stability than use of a single
Oxford-12 or SF-36 outcome measures. Thirty-three patients lateral plate with wires; however, the authors of that report
were available for radiographic evaluation at a minimum of two acknowledged the disadvantage of the requisite additional soft-
years postoperatively; bone ingrowth of the stem was noted in tissue dissection required with the double-plate strategy48.
97% of them, and a stable fibrous union was noted in 3%. No Wilson et al.49 reported that the ideal construct for a fracture
significant difference in the prevalence of stable fractures was with a stable femoral stem was a lateral plate supplemented
found when bowed and straight stems were compared or when with an anterior allograft cortical strut. Although the ideal
10-in (25-cm) and 8-in (20.3-cm) stems were compared. stability has been considered in these studies, the minimum
However, 10-in stems had been used more frequently in the stability required for successful union remains unknown. This
group with an unstable fracture. issue affects all of the reported biomechanical findings and is
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fixation devices, such as locking plates. These issues should be


considered in the interpretation of in vitro biomechanical
studies.

Intraoperative Acetabular Fractures


Epidemiology and Etiology
Intraoperative periprosthetic fractures of the acetabulum are
less commonly recognized than femoral fractures. They are
reportedly more common in association with uncemented
cups20,50-53. In 1974, McElfresh and Coventry54 reported only
one intraoperative periprosthetic acetabular fracture during
5400 total hip arthroplasties performed with cement (a prev-
alence of <0.02%); however, as a result of the infrequent at-
tention to intraoperative acetabular fractures in the literature,
this may be an underestimate. Haidukewych et al.19 reviewed a
series of 7121 primary total hip arthroplasties and reported an
Fig. 4-A
intraoperative acetabular fracture during twenty-one (0.4%) of
Figs. 4-A and 4-B Treatment of a type-B3 fracture with cerclage wire 5359 performed with an uncemented acetabular component.
fixation supplemented with an allograft cortical strut. Fig. 4-A Intra-
No acetabular fractures occurred during any of the 1762 pro-
operative appearance.
cedures done with a cemented component. Of the twenty-one
fractures, seventeen were stable and four were treated with
supplemental screw fixation. Elliptical monoblock cups were
relevant given the need for the use of allograft bone, which may associated with the highest risk of fracture, with a prevalence of
not be readily available in all centers, and the additional soft- 3.5% (twelve) of 339 compared with a prevalence of 0.09%
tissue dissection required to place the grafts. We are not aware (two of 2198) in association with hemispherical modular
of any studies comparing the combination of standard dy- shells. Sharkey et al.55 reported that thirteen intraoperative
namic compression plates and allograft with more modern acetabular fractures occurred during the insertion of un-
cemented components; nine were diagnosed intraoperatively.
Various treatment methods were employed, including addi-
tional screw fixation, autogenous bone-grafting, and protected
weight-bearing. Two cases required revision of the acetabular
component, one patient died in the immediate postoperative
period, and ten acetabular components remained unrevised
after a maximum duration of follow-up of fifty-nine months.
Intraoperative acetabular fractures most frequently occur
during insertion of the component55. This is due to the un-
derreaming required for the fixation of a cementless acetabular
component when no screws are used. In order to minimize the
risk of fracture, it has been suggested that components not be
oversized by >2 mm55. It should be noted that the 2-mm rule
applies for average acetabular diameters. When very large cups
are used, it may be appropriate to oversize by >2 mm, de-
pending on the clinical circumstances and the quality of the
bone, although we are not aware of any data regarding this
issue. Patient factors contributing to the risk of these fractures
include osteopenia, metabolic bone disease, and osteolytic
defects. Factors related to the operative technique include ag-
gressive reaming and the use of a cup in which the rim cir-
cumference is larger than the nominal diameter of the cup.

Diagnosis
Maintaining a high index of suspicion for intraoperative ace-
tabular fractures is important as they can be difficult to iden-
tify. When a concern arises regarding a possible fracture, a full
Fig. 4-B clinical and radiographic assessment of the affected area is
Postoperative anteroposterior radiograph. required. This should include careful determination of com-
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Fig. 5-A
Figs. 5-A and 5-B Use of cerclage wire fixation for treatment of a type-C2 fracture of the left femur.
Fig. 5-A Anteroposterior radiograph of the pelvis.

ponent stability with use of intraoperative stress testing of the moval and are further classified as type A if there is <50% loss of
pelvis and the acetabular component, and it may require re- acetabular bone stock and as type B if there is >50% loss of
moval of the cup to fully examine the acetabulum. acetabular bone stock. The remaining fracture types comprise
postoperative injuries and are beyond the scope of this review.
Classification In our opinion, this is a cumbersome classification system and
Intraoperative acetabular fractures were classified by Callaghan the most important factors are whether the implant is stable in
et al.17,18 on the basis of in vitro investigation. Their classifi- association with the intraoperative or postoperative fracture
cation system identifies four types of fractures on the basis of and whether there is pelvic discontinuity in the presence of
the anatomic location: anterior wall, transverse, inferior lip, failure of the acetabular component with massive osteolysis.
and posterior wall. Therefore, we propose the following addition to the Vancouver
Della Valle et al.56 classified acetabular fractures, includ- classification system of periprosthetic fractures11,39, as it applies
ing both intraoperative and postoperative types. Type-I frac- to the acetabulum intraoperatively: type I—an undisplaced
tures occur intraoperatively at the time of insertion of the fracture that does not compromise the stability of the com-
acetabular component and are subclassified as type A if they ponent; type II—an undisplaced fracture that potentially
are diagnosed intraoperatively, are undisplaced, and are asso- compromises the stability of the reconstruction, such as a
ciated with a stable component; as type B if they are diagnosed transverse fracture of the acetabulum (with pelvic disconti-
intraoperatively but are associated with a displaced fracture; nuity or dissociation) or an oblique fracture that separates the
and as type C if they are diagnosed postoperatively. It can be anterior column and dome from the posterior column (a
difficult to differentiate between undisplaced and displaced much less common injury); and type III—a displaced fracture.
fractures intraoperatively, which highlights the importance of By definition, if there is substantial displacement, the fixation
obtaining and considering both intraoperative and radiographic of the cup will be compromised unless the fracture is somehow
findings. Type-II injuries occur at the time of component re- stabilized (Figs. 7-A and 7-B).
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study because of the small sample size, there is a trend toward


failure if an unstable fracture is not stabilized, as was seen in the
cases of the unrecognized fractures. We are not aware of any
comparative studies in the literature regarding the treatment of
acetabular fractures.
Della Valle et al.56 offered recommendations for treat-
ment of intraoperative acetabular fractures. According to these
authors, when a patient has a nondisplaced fracture with a
stable component, the prosthesis can be left in situ and stan-
dard total hip arthroplasty rehabilitation protocols may be
applied. If the component is unstable, the structural integrity
of the anterior and posterior columns must be assessed and
supplemental screw fixation should be used if necessary. Con-
sideration should be given to the use of a so-called jumbo
revision cup if there is marked instability and bone loss that
necessitates the use of a larger acetabular component. These
fractures should be further treated with bone graft, and the
patient should maintain protected weight-bearing postopera-
tively until the fracture has healed. If there is substantial
motion at the fracture site, including the presence of pelvic
dissociation, the posterior column should be treated with re-
duction and internal fixation (with, for example, a pelvic
reconstruction plate on the posterior column; Figs. 7-A and
7-B). After the pelvis has been stabilized, the acetabulum may
be reconstructed with standard techniques. We are not aware
of any prospective studies in which these treatment recom-
mendations were investigated.
Posterior column internal fixation alone may not be
sufficient for some cases of pelvic dissociation; alternate tech-
niques may be required. Fixation with a reconstruction cage
and bone-grafting may be appropriate in such cases, as the
Fig. 5-B cage will bridge from inferiorly to superiorly and allow tem-
Anteroposterior radiograph of the affected femur. porary stabilization of the fracture while the bone graft in-
corporates and the fracture heals. If acetabular bone loss is
Although this classification has not been validated or so severe that a standard hemispherical cementless cup may
widely utilized, it has been useful in the assessment and man- provide unreliable fixation and bone ingrowth, an alternate
agement of intraoperative acetabular fractures at our center. fixation method may be required. Such cases may be treated
with a porous tantalum substrate such as the one used for the
Treatment and Results Trabecular Metal Revision Cup (Zimmer, Warsaw, Indiana),
The goal of treatment is to maximize hip function. Although which allows more predictable bone ingrowth. In 2005,
the exact treatment methods may change over time, the prin- Springer et al.57 reported on seven women who had a delayed
ciples include fracture stabilization, prevention of propagation transverse fracture of the acetabulum after undergoing a re-
of the fracture, maintenance of component alignment and vision total hip arthroplasty with a Trabecular Metal Cup. The
stability, and achievement of fracture union11,13,39. authors thought that these fractures were not intraoperative
Little attention has been paid in the literature to the but were related to the weak remaining bone stock, which
treatment and outcome of intraoperative acetabular peri- failed after resumption of activity. The occurrence of these
prosthetic fractures. In the study by Sharkey et al.55, of thirteen fractures and their displacement with time suggest that a cup
fractures, six were treated with additional acetabular screw that bridges from superiorly to inferiorly and has a high ca-
fixation, two were deemed stable and not in need of additional pacity for bone ingrowth may not be sufficient in cases of
fixation or a change in postoperative rehabilitation, and one severe bone loss. For this reason, pelvic discontinuity should
did not require additional fixation but was treated with non- not be treated with a hemispherical cup alone. Instead, stability
weight-bearing for eight weeks postoperatively. Fracture union may be achieved by the addition of a reconstruction cage that is
was observed in all nine cases. The remaining four fractures, designed to fit within the cup and is fixed to the ischium
identified postoperatively, were associated with evidence of inferiorly and to the ilium superiorly. An all-polyethylene cup
loosening on follow-up radiographs, and two required revision. can then be cemented into the reconstruction cage (Fig. 8).
While firm conclusions cannot be made on the basis of this This is the so-called cup-cage-construct technique. Boscainos
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Fig. 6-A
Figs. 6-A, 6-B, and 6-C Open reduction and internal fixation of a type-C3 fracture with
use of a large-fragment locking plate. Fig. 6-A Anteroposterior radiograph of the pelvis.

et al.58 reported good early results in fourteen patients treated studies57,58 only described the use of this technique in revision
with the cup-cage construct, although the rate of recurrent total hip arthroplasty; consequently, the use of this technique
dislocation was high, with two of the fourteen patients re- for intraoperative acetabular fractures has not been reported,
quiring revision to a constrained acetabular liner. Both of these to our knowledge.

Fig. 6-B Fig. 6-C


Anteroposterior (Fig. 6-B) and lateral (Fig. 6-C) radiographs of the femur.
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Fig. 7-A
Figs. 7-A and 7-B A type-III intraoperative acetabular fracture of the floor and both
columns of the acetabulum. Fig. 7-A Initial anteroposterior radiograph of the pelvis,
demonstrating the fracture.

Prevention of Intraoperative Periprosthetic Fractures rence4,13. This includes obtaining a detailed history and for-
Prevention of periprosthetic fractures requires preoperative mulating an operative plan. Full-length, adequate preoperative
planning to assess risk factors associated with their occur- radiographs, including Judet views, should be made in order to

Fig. 7-B
Anteroposterior radiograph of the pelvis following open reduction and internal fixation of the ace-
tabulum with an anterior column screw and a posterior column plate followed by acetabular
reconstruction and implantation of a standard femoral component.
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Fig. 8
Treatment of a posterior column fracture with open reduction and internal fixation with use of a
pelvic reconstruction plate followed by acetabular reconstruction with a jumbo revision cup in
the right hip. In the left hip, a type-III acetabular fracture was managed with a cup-cage construct.

fully appreciate any deformity or areas of bone loss that may tive radiographs should be made to assess for potential frac-
increase susceptibility to fracture. All potential reconstructive tures that were not appreciated intraoperatively.
options should be carefully planned with use of templates on
preoperative radiographs to anticipate the likely sizes of the Overview
components. It should be emphasized that, if the implant Intraoperative periprosthetic fractures are an increasingly com-
chosen on the basis of the templating is not stable, the surgeon mon problem. They are particularly likely to occur at the time of
should carefully inspect the femur to make sure that there is no a revision total hip arthroplasty in which uncemented compo-
fracture that is creating instability and failure of fixation. nents are used. Appropriate steps should be taken to minimize
During the course of the operation, careful attention must the risk of fracture through the identification of high-risk situa-
be given to the parts of the procedure that are associated with the tions. A high index of suspicion is required to identify possible
highest risk of fracture, such as hip dislocation, cement removal fractures. The Vancouver classification11,39 may be used to facil-
(in revision cases), canal preparation, and component inser- itate an understanding of the fracture pattern and to choose
tion. Adequate soft-tissue releases are necessary to minimize the treatment. Management should be directed toward ensuring
force required to obtain sufficient exposure. If necessary, ad- component stability, thereby maximizing the chance for fracture
junctive surgical strategies, such as an extended trochanteric union and a satisfactory outcome. Future comparative studies of
osteotomy, should be considered. This is particularly relevant to fixation techniques for intraoperative fractures are necessary to
the removal of well-fixed cementless and precoated cemented optimize management of these injuries. n
stems11,49. The use of cerclage wires at the distal extent of a
trochanteric osteotomy, or of a periprosthetic fracture, should
be considered to prevent propagation of the fracture. Appro-
priate thin hemispherical osteotomes could be used for the Darin Davidson, MD, MHSc
acetabular component, and trephines should be used for the Jeffrey Pike, MD
femoral stem13. During canal preparation, eccentric reaming Donald Garbuz, MD, MHSc, FRCSC
should be avoided and consideration should be given to pro- Clive P. Duncan, MB, MSc, FRCSC
Bassam A. Masri, MD, FRCSC
tecting areas of bone loss with cerclage wires or bone graft. In Division of Lower Limb Reconstruction and Oncology (D.G.),
the setting of complex revision, intraoperative radiographs can Department of Orthopaedics (D.D., J.P., C.P.D., and B.A.M.), University
be made to ensure central placement of the guidewire within of British Columbia, 3114-910 West 10th Avenue, Vancouver, BC V5Z
the medullary canal prior to reaming. Immediate postopera- 4E3, Canada. E-mail address for B.A. Masri: bas.masri@vch.ca
2011
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References
1. Beals RK, Tower SS. Periprosthetic fractures of the femur. An analysis of 93 a porous-coated, distally slotted, fluted femoral stem. Clin Orthop Relat Res.
fractures. Clin Orthop Relat Res. 1996;327:238-46. 2004;425:173-6.
2. Berry DJ. Epidemiology: hip and knee. Orthop Clin North Am. 1999;30:183-90. 28. Gie GA, Linder L, Ling RS, Simon JP, Slooff TJ, Timperley AJ. Impacted
cancellous allografts and cement for revision total hip arthroplasty. J Bone
3. Christensen CM, Seger BM, Schultz RB. Management of intraoperative femur
Joint Surg Br. 1993;75:14-21.
fractures associated with revision hip arthroplasty. Clin Orthop Relat Res.
1989;248:177-80. 29. Leopold SS, Berger RA, Rosenberg AG, Jacobs JJ, Quigley LR, Galante JO.
Impaction allografting with cement for revision of the femoral component. A mini-
4. Duwelius PJ, Schmidt AH, Kyle RF, Talbott V, Ellis TJ, Butler JB. A prospective,
mum four-year follow-up study with use of a precoated femoral stem. J Bone Joint
modernized treatment protocol for periprosthetic femur fractures. Orthop Clin North
Surg Am. 1999;81:1080-92.
Am. 2004;35:485-92, vi.
5. Franklin J, Malchau H. Risk factors for periprosthetic femoral fracture. Injury. 30. Pekkarinen J, Alho A, Lepistö J, Ylikoski M, Ylinen P, Paavilainen T. Impaction
2007;38:655-60. bone grafting in revision hip surgery. A high incidence of complications. J Bone Joint
Surg Br. 2000;82:103-7.
6. Garbuz DS, Masri BA, Duncan CP. Periprosthetic fractures of the femur:
principles of prevention and management. Instr Course Lect. 1998;47:237-42. 31. Piccaluga F, González Della Valle A, Encinas Fernández JC, Pusso R. Revision
of the femoral prosthesis with impaction allografting and a Charnley stem. A 2- to
7. Kelley SS. Periprosthetic femoral fractures. J Am Acad Orthop Surg. 12-year follow-up. J Bone Joint Surg Br. 2002;84:544-9.
1994;2:164-72.
32. Ornstein E, Atroshi I, Franzén H, Johnsson R, Sandquist P, Sundberg M.
8. Lewallen DG, Berry DJ. Periprosthetic fracture of the femur after total hip Early complications after one hundred and forty-four consecutive hip revisions
arthroplasty: treatment and results to date. Instr Course Lect. 1998;47:243-9. with impacted morselized allograft bone and cement. J Bone Joint Surg Am.
9. Lindahl H. Epidemiology of periprosthetic femur fracture around a total hip 2002;84:1323-8.
arthroplasty. Injury. 2007;38:651-4. 33. Halliday BR, English HW, Timperley AJ, Gie GA, Ling RS. Femoral impaction
10. Lindahl H, Garellick G, Regnér H, Herberts P, Malchau H. Three hundred and grafting with cement in revision total hip replacement. Evolution of the technique
twenty-one periprosthetic femoral fractures. J Bone Joint Surg Am. 2006;88:1215-22. and results. J Bone Joint Surg Br. 2003;85:809-17.

11. Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation and 34. Farfalli GL, Buttaro MA, Piccaluga F. Femoral fractures in revision hip surgeries
treatment. Clin Orthop Relat Res. 2004;420:80-95. with impacted bone allograft. Clin Orthop Relat Res. 2007;462:130-6.

12. McLauchlan GJ, Robinson CM, Singer BR, Christie J. Results of an opera- 35. Asayama I, Kinsey TL, Mahoney OM. Two-year experience using a limited-
tive policy in the treatment of periprosthetic femoral fracture. J Orthop Trauma. incision direct lateral approach in total hip arthroplasty. J Arthroplasty.
1997;11:170-9. 2006;21:1083-91.

13. Mitchell PA, Greidanus NV, Masri BA, Garbuz DS, Duncan CP. The prevention 36. Moroni A, Faldini C, Piras F, Giannini S. Risk factors for intraoperative
of periprosthetic fractures of the femur during and after total hip arthroplasty. Instr femoral fractures during total hip replacement. Ann Chir Gynaecol. 2000;89:
Course Lect. 2003;52:301-8. 113-8.

14. Mont MA, Maar DC, Krackow KA, Hungerford DS. Hoop-stress fractures of the 37. Meek RM, Garbuz DS, Masri BA, Greidanus NV, Duncan CP. Intraoperative
proximal femur during hip arthroplasty. Management and results in 19 cases. fracture of the femur in revision total hip arthroplasty with a diaphyseal fitting stem.
J Bone Joint Surg Br. 1992;74:257-60. J Bone Joint Surg Am. 2004;86:480-5.

15. Schwartz JT Jr, Mayer JG, Engh CA. Femoral fracture during non-cemented total 38. Learmonth ID. The management of periprosthetic fractures around the femoral
hip arthroplasty. J Bone Joint Surg Am. 1989;71:1135-42. stem. J Bone Joint Surg Br. 2004;86:13-9.

16. Tower SS, Beals RK. Fractures of the femur after hip replacement: the Oregon 39. Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr
experience. Orthop Clin North Am. 1999;30:235-47. Course Lect. 1995;44:293-304.
17. Callaghan JJ. Periprosthetic fractures of the acetabulum during and following 40. Brady OH, Garbuz DS, Masri BA, Duncan CP. The reliability and validity of the
total hip arthroplasty. Instr Course Lect. 1998;47:231-5. Vancouver classification of femoral fractures after hip replacement. J Arthroplasty.
2000;15:59-62.
18. Callaghan JJ, Kim YS, Pederson DR, Brown TD. Periprosthetic fractures of the
acetabulum. Orthop Clin North Am. 1999;30:221-34. 41. Larson JE, Chao EY, Fitzgerald RH. Bypassing femoral cortical defects with
cemented intramedullary stems. J Orthop Res. 1991;9:414-21.
19. Haidukewych GJ, Jacofsky DJ, Hanssen AD, Lewallen DG. Intraoperative frac-
tures of the acetabulum during primary total hip arthroplasty. J Bone Joint Surg Am. 42. Khan MA, O’Driscoll M. Fractures of the femur during total hip replacement
2006;88:1952-6. and their management. J Bone Joint Surg Br. 1977;59:36-41.
20. Peterson CA, Lewallen DG. Periprosthetic fracture of the acetabulum after total 43. Chappell JD, Lachiewicz PF. Fracture of the femur in revision hip arthroplasty
hip arthroplasty. J Bone Joint Surg Am. 1996;78:1206-13. with a fully porous-coated component. J Arthroplasty. 2005;20:234-8.
21. Davis CM 3rd, Berry DJ, Harmsen WS. Cemented revision of failed un- 44. Berend KR, Lombardi AV Jr, Mallory TH, Chonko DJ, Dodds KL, Adams JB.
cemented femoral components of total hip arthroplasty. J Bone Joint Surg Am. Cerclage wires or cables for the management of intraoperative fracture associ-
2003;85:1264-9. ated with a cementless, tapered femoral prosthesis: results at 2 to 16 years.
J Arthroplasty. 2004;19 (7 Suppl 2):17-21.
22. Egan KJ, Di Cesare PE. Intraoperative complications of revision hip arthro-
plasty using a fully porous-coated straight cobalt-chrome femoral stem. J Arthro- 45. Paprosky WG, Aribindi R. Hip replacement: treatment of femoral bone loss
plasty. 1995;10 Suppl:S45-51. using distal bypass fixation. Instr Course Lect. 2000;49:119-30.
23. Sarvilinna R, Huhtala HS, Sovelius RT, Halonen PJ, Nevalainen JK, Pajamäki 46. Schmotzer H, Tchejeyan GH, Dall DM. Surgical management of intra- and
KJ. Factors predisposing to periprosthetic fracture after hip arthroplasty: a case postoperative fractures of the femur about the tip of the stem in total hip arthro-
(n = 31)-control study. Acta Orthop Scand. 2004;75:16-20. plasty. J Arthroplasty. 1996;11:709-17.
24. Taylor MM, Meyers MH, Harvey JP Jr. Intraoperative femur fractures during 47. Dennis MG, Simon JA, Kummer FJ, Koval KJ, DiCesare PE. Fixation of peri-
total hip replacement. Clin Orthop Relat Res. 1978;137:96-103. prosthetic femoral shaft fractures occurring at the tip of the stem: a biomechanical
study of 5 techniques. J Arthroplasty. 2000;15:523-8.
25. Malkani AL, Lewallen DG, Cabanela ME, Wallrichs SL. Femoral component
revision using an uncemented, proximally coated, long-stem prosthesis. J Arthro- 48. Kuptniratsaikul S, Brohmwitak C, Techapongvarachai T, Itiravivong P. Plate-
plasty. 1996;11:411-8. screw-wiring technique for the treatment of periprosthetic fracture around the hip:
a biomechanical study. J Med Assoc Thai. 2001;84 Suppl 1:S415-22.
26. Lerch M, Windhagen H, von Lewinski G, Thorey F. [Intraoperative
femoral fractures during the implantation of the cementless BiCONTACT 49. Wilson D, Frei H, Masri BA, Oxland TR, Duncan CP. A biomechanical study
stem: a matched-pair analysis of 84 patients]. Z Orthop Unfall. 2007;145: comparing cortical onlay allograft struts and plates in the treatment of peri-
574-8. German. prosthetic femoral fractures. Clin Biomech (Bristol, Avon). 2005;20:70-6.
27. Issack PS, Guerin J, Butler A, Marwin SE, Bourne RB, Rorabeck CH, Barrack 50. Adler E, Stuchin SA, Kummer FJ. Stability of press-fit acetabular cups.
RL, Di Cesare PE. Intraoperative complications of revision hip arthroplasty using J Arthroplasty. 1992;7:295-301.
2012
T H E J O U R N A L O F B O N E & J O I N T S U R G E RY J B J S . O R G
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I N T R A O P E R AT I V E P E R I P R O S T H E T I C F R A C T U R E S D U R I N G
V O L U M E 9 0-A N U M B E R 9 S E P T E M B E R 2 008
d d
T O TA L H I P A R T H R O P L A S T Y

51. Curtis MJ, Jinnah RH, Wilson VD, Hungerford DS. The initial stability of 56. Della Valle CJ, Momberger NG, Paprosky WG. Periprosthetic fractures of the
uncemented acetabular components. J Bone Joint Surg Br. 1992;74:372-6. acetabulum associated with a total hip arthroplasty. Instr Course Lect.
2003;52:281-90.
52. MacKenzie JR, Callaghan JJ, Pedersen DR, Brown TD. Areas of contact and
extent of gaps with implantation of oversized acetabular components in total hip
arthroplasty. Clin Orthop Relat Res. 1994;298:127-36.
57. Springer BD, Berry DJ, Cabanela ME, Hanssen AD, Lewallen DG. Early
53. Stiehl JB, MacMillan E, Skrade DA. Mechanical stability of porous-coated postoperative transverse pelvic fracture: a new complication related to re-
acetabular components in total hip arthroplasty. J Arthroplasty. 1991;6:295-300. vision arthroplasty with an uncemented cup. J Bone Joint Surg Am. 2005;
87:2626-31.
54. McElfresh EC, Coventry MB. Femoral and pelvic fractures after total hip
arthroplasty. J Bone Joint Surg Am. 1974;56:483-92.
55. Sharkey PF, Hozack WJ, Callaghan JJ, Kim YS, Berry DJ, Hanssen AD, LeWallen 58. Boscainos PJ, Kellett CF, Maury AC, Backstein D, Gross AE. Management of
DG. Acetabular fracture associated with cementless acetabular component inser- periacetabular bone loss in revision hip arthroplasty. Clin Orthop Relat Res.
tion: a report of 13 cases. J Arthroplasty. 1999;14:426-31. 2007;465:159-65.