Advertisement

International Orthopaedics

, Volume 39, Issue 10, pp 1909–1920 | Cite as

Periprosthetic femoral fractures—incidence, classification problems and the proposal of a modified classification scheme

  • Stephan Frenzel
  • Vilmos Vécsei
  • Lukas Negrin
Original Paper

Abstract

Introduction

The increasing incidence of periprosthetic fractures correlates directly with the year-after-year increasing frequency of primary joint replacement surgery. The most common fracture localisation is the femur. The undisputed leader in frequency is the fracture that occurs around a total hip arthroplasty. Unfortunately, no general epidemiologic data exist dealing with exact fracture incidence numbers. Furthermore, existing classifications are lacking important information like time point of fracture occurrence, type of the implanted prosthesis and implantation technique (cemented vs. cementless). Additionally, information about mechanical quality of the bone structure and the fracture type are also missing in part.

Methods

We scanned the literature for adequate and widely used classifications in the field of hip and knee arthroplasty. In a next step we analyzed those classification systems in order to find out to what extent they are able to describe the specific aspects of the fracture event. Therefore we compared the existing classifications and presented their most relevant emphasis. Furthermore, we looked at our own patient population to evaluate incidence of fracture occurrence over time and percentage of loosened components.

Results

The existing classification systems address themselves specifically to the task of describing fracture localization and to some extent fracture type, or combine these two in order to calculate the possibility of loosening of the implanted prosthesis. Some of the important criteria like mechanical quality of the bone stock, primary implantation technique or time point of the prosthesis loosening (prior to or because of the fracture) remain ignored. The incidence of periprosthetic femur fractures at our department increased approximately 2.5 fold over the past two decades. The risk of suffering from a periprosthetic fracture was substantially higher after THA than after TKA. We observed a loose femoral component of the THA in about 45 % of the cases. Finally, we postulate the application of a modified classification for periprosthetic fractures as an alternative to the already published ones; not only for the femur, but also universally for all joints with an arthroplasty.

Conclusion

The classification that is introduced in this study allows, in our opinion, a differentiated reflection of the given post-traumatic pathologic changes and enables the description of the fracture itself according to a generally accepted fracture classification scheme.

Keywords

Periprosthetic fractures Classification Incidence Femur Arthroplasty 

Notes

Acknowledgments

The authors declare that they have no disclosures and did not receive any financial support for this manuscript.

References

  1. 1.
    Ahuja S, Chatterji S (2002) The Mennen femoral plate for fixation of periprosthetic femoral fractures following hip arthroplasty. Injury 33(1):47–50CrossRefPubMedGoogle Scholar
  2. 2.
    Beals RK, Tower SS (1996) Periprosthetic fractures of the femur. An analysis of 93 fractures. Clin Orthop Relat Res 327:238–246CrossRefPubMedGoogle Scholar
  3. 3.
    Berry DJ (1999) Epidemiology: hip and knee. Orthop Clin North Am 30(2):183–190CrossRefPubMedGoogle Scholar
  4. 4.
    Berry DJ (2003) Periprosthetic fractures associated with osteolysis: a problem on the rise. J Arthroplasty 18(3 Suppl 1):107–111CrossRefPubMedGoogle Scholar
  5. 5.
    Bethea JS 3rd, DeAndrade JR, Fleming LL, Lindenbaum SD, Welch RB (1982) Proximal femoral fractures following total hip arthroplasty. Clin Orthop Relat Res 170:95–106PubMedGoogle Scholar
  6. 6.
    Booth RE Jr (1995) Supracondylar fractures: all or nothing. Orthopedics 18(9):921–922PubMedGoogle Scholar
  7. 7.
    Brady OH, Garbuz DS, Masri BA, Duncan CP (1999) Classification of the hip. Orthop Clin North Am 30(2):215–220CrossRefPubMedGoogle Scholar
  8. 8.
    Brady OH, Garbuz DS, Masri BA, Duncan CP (2000) The reliability and validity of the Vancouver classification of femoral fractures after hip replacement. J Arthroplasty 15(1):59–62CrossRefPubMedGoogle Scholar
  9. 9.
    Buecking B, Bliemel C, Ruchholtz S (2013) Periprosthetic fractures—incidence, risk factors, classification, and therpeutic concepts. Orthop Unfall Praxis 5:259–267Google Scholar
  10. 10.
    Capello WN, D’Antonio JA, Naughton M (2014) Periprosthetic fractures around a cementless hydroxyapatite-coated implant: a new fracture pattern is described. Clin Orthop Relat Res 472(2):604–610PubMedCentralCrossRefPubMedGoogle Scholar
  11. 11.
    Chalidis BE, Tsiridis E, Tragas AA, Stavrou Z, Giannoudis PV (2007) Management of periprosthetic patellar fractures. A systematic review of literature. Injury 38(6):714–724CrossRefPubMedGoogle Scholar
  12. 12.
    Cooke PH, Newman JH (1988) Fractures of the femur in relation to cemented hip prostheses. J Bone Joint Surg Br 70(3):386–389PubMedGoogle Scholar
  13. 13.
    Corten K, Vanrykel F, Bellemans J, Frederix PR, Simon JP, Broos PL (2009) An algorithm for the surgical treatment of periprosthetic fractures of the femur around a well-fixed femoral component. J Bone Joint Surg Br 91(11):142430Google Scholar
  14. 14.
    Della Rocca GJ, Leung KS, Pape HC (2011) Periprosthetic fractures: epidemiology and future projections. J Orthop Trauma 25(Suppl 2):S66–S70CrossRefPubMedGoogle Scholar
  15. 15.
    DiGioia AM 3rd, Rubash HE (1991) Periprosthetic fractures of the femur after total knee arthroplasty. A literature review and treatment algorithm. Clin Orthop Relat Res 271:135–142PubMedGoogle Scholar
  16. 16.
    Duncan CP, Haddad FS (2014) The unified classification system (UCS): improving our understanding of periprosthetic fractures. Bone Joint J 96-B(6):713–716CrossRefPubMedGoogle Scholar
  17. 17.
    Duncan CP, Masri BA (1995) Fractures of the femur after hip replacement. Instr Course Lect 44:293–304PubMedGoogle Scholar
  18. 18.
    Fitzgerald RH Jr, Brindley GW, Kavanagh BF (1988) The uncemented total hip arthroplasty. Intraoperative femoral fractures. Clin Orthop Relat Res 235:61–66PubMedGoogle Scholar
  19. 19.
    Franklin J, Malchau H (2007) Risk factors for periprosthetic femoral fracture. Injury 38(6):655–660CrossRefPubMedGoogle Scholar
  20. 20.
    Fredin HO, Lindberg H, Carlsson AS (1987) Femoral fracture following hip arthroplasty. Acta Orthop Scand 58(1):20–22CrossRefPubMedGoogle Scholar
  21. 21.
    Froberg L, Troelsen A, Brix M (2012) Periprosthetic Vancouver type B1 and C fractures treated by locking-plate osteosynthesis: fracture union and reoperations in 60 consecutive fractures. Acta Orthop 83(6):648–652PubMedCentralCrossRefPubMedGoogle Scholar
  22. 22.
    Hagel A, Siekmann H, Delank K (2014) Periprothetische femurfraktur – eine interdisziplinäre herausforderung. Dtsch Arztebl Int 111(39):658–664PubMedCentralPubMedGoogle Scholar
  23. 23.
    Hessler H, Oestern HJ (2005) Periprothetische Frakturen. Op J 21:120–127CrossRefGoogle Scholar
  24. 24.
    Hoffmann MF, Burgers TA, Mason JJ, Williams BO, Sietsema DL, Jones CB (2014) Biomechanical evaluation of fracture fixation constructs using a variable-angle locked periprosthetic femur plate system. Injury 45(7):103541CrossRefGoogle Scholar
  25. 25.
    Horowitz IB, Lenobel MI (1954) Artificial hip prothesis in acute and nonunion fractures of femoral neck. JAMA 155(6):564–567CrossRefGoogle Scholar
  26. 26.
    Jensen JS, Barfod G, Hansen D, Larsen E, Linde F, Menck H, Olsen B (1988) Femoral shaft fracture after hip arthroplasty. Acta Orthop Scand 59(1):9–13CrossRefPubMedGoogle Scholar
  27. 27.
    Johansson JE, McBroom R, Barrington TW, Hunter GA (1981) Fracture of the ipsilateral femur in patients with total hip replacement. J Bone Joint Surg Am 63(9):1435–1442PubMedGoogle Scholar
  28. 28.
    Kellam JF, Audigé L (2007) Fracture classification. In: Rüedi TP, Buckley RE, Morgan CG (eds) AO principles of fracture management, 2nd edn. Thieme, StuttgartGoogle Scholar
  29. 29.
    Larson JE, Chao EY, Fitzgerald RH (1991) Bypassing femoral cortical defects with cemented intramedullary stems. J Orthop Res 9(3):414–421CrossRefPubMedGoogle Scholar
  30. 30.
    Lindahl H (2007) Epidemiology of periprosthetic femur fracture around a total hip arthroplasty. Injury 38(6):651–654CrossRefPubMedGoogle Scholar
  31. 31.
    Lindahl H, Garellick G, Regnér H, Herberts P, Malchau H (2006) Three hundred and twenty-one periprosthetic femoral fractures. J Bone Joint Surg Am 88(6):1215–1222CrossRefPubMedGoogle Scholar
  32. 32.
    Lindahl H, Malchau H, Herberts P, Garellick G (2005) Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish national Hip arthroplasty register. J Arthroplasty 20(7):857–865CrossRefPubMedGoogle Scholar
  33. 33.
    Lindahl H, Malchau H, Odén A, Garellick G (2006) Risk factors for failure after treatment of a periprosthetic fracture of the femur. J Bone Joint Surg Br 88(1):26–30CrossRefPubMedGoogle Scholar
  34. 34.
    Lindahl H, Oden A, Garellick G, Malchau H (2007) The excess mortality due to periprosthetic femur fracture. A study from the Swedish national hip arthroplasty register. Bone 40(5):1294–1298CrossRefPubMedGoogle Scholar
  35. 35.
    Little JP (1995) Consistency of ASA grading. Anaesthesia 50(7):658–659PubMedGoogle Scholar
  36. 36.
    Mabrey JD (1996) Periprosthetic fractures of the lower extremity. In Rockwood and Green’s: Fractures in adults, 4th edn. Lipincott-Raven, PhiladelphiaGoogle Scholar
  37. 37.
    Masri BA, Meek RM, Duncan CP (2004) Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res 420:80–95CrossRefPubMedGoogle Scholar
  38. 38.
    Merkel KD, Johnson EW Jr (1986) Supraconylar fracture of the femur after total knee arthroplasty. J Bone Joint Surg Am 68(1):29–43PubMedGoogle Scholar
  39. 39.
    Moazen M, Mak JH, Etchels LW, Jin Z, Wilcox RK, Jones AC, Tsiridis E (2014) Periprosthetic femoral fracture- a biomechanical comparison between Vancouver type B1 and B2 fixation methods. J Arthroplsty 29(3):495–500CrossRefGoogle Scholar
  40. 40.
    Mont MA, Maar DC (1994) Fractures of the ipsilateral femur after hip arthroplasty. A statistical analysis of outcome based on 487 patients. J Arthroplasty 9(5):511–519CrossRefPubMedGoogle Scholar
  41. 41.
    Naqvi GA, Baig SA, Awan N (2012) Interobserver and intraobserver reliability and validity of the Vancouver classification system of periprosthetic femoral fractures after hip arthroplasty. J Arthroplasty 27(6):1047–1050CrossRefPubMedGoogle Scholar
  42. 42.
    Neer CS 2nd, Grantham SA, Shelton ML (1967) Supracondylar fracture of the adult femur. A study of one hundred and ten cases. J Bone Joint Surg Am 49(4):591–613PubMedGoogle Scholar
  43. 43.
    Ochsner PE (ed) (2003) Die hüfttotalendoprothese: implantationstechnik und lokale komplikationen. Springer, BerlinGoogle Scholar
  44. 44.
    Ohly NE, Whitehouse MR, Duncan CP (2014) Periprosthetic femoral fractures in total hip arthroplasty. Hip Int 24(6):556–567CrossRefPubMedGoogle Scholar
  45. 45.
    Park SK, Kim YG, Kim SY (2011) Treatment of periprosthetic femoral fractures in hip arthroplasty. Clin Orthop Surg 3(2):101–106PubMedCentralCrossRefPubMedGoogle Scholar
  46. 46.
    Probst A, Schneider T, Hankemeier S, Brug E (2003) The prosthesis nail—a new stable fixation device for periprosthetic fractures and critical fractures of the proximal femur. Unfallchirurg 106(9):722–731CrossRefPubMedGoogle Scholar
  47. 47.
    Raschke MJ, Stöckle U (2003) Klassifikationssystem der AG für Alterstraumatologie DGU. www.dgu-online.de. Accessed 19 August 2015
  48. 48.
    Rayan F, Dodd M, Haddad FS (2008) European validation of the Vancouver classification of periprosthetic proximal femoral fractures. J Bone Joint Surg Br 90(12):1576–1579CrossRefPubMedGoogle Scholar
  49. 49.
    Reindl R, Schatzker J (2012) Hüftgelenk und Femur: Periprothetische Frakturen. In: Haas NP, Krettek C (ed) Tscherne: Unfallchirurgie. Springer, BerlinGoogle Scholar
  50. 50.
    Rorabeck CH, Taylor JW (1999) Classification of periprosthetic fractures complicating total knee arthroplasty. Orthop Clin North Am 30(2):209–214CrossRefPubMedGoogle Scholar
  51. 51.
    Rupprecht M, Schlickewei C, Fensky F, Morlock M, Püschel K, Rueger JM, Lehman W (2014) [Periprosthetic and interimplant femoral fractures : Biomechanical analysis]. Unfallchirurg. Jun 5 [Epub ahead of print]Google Scholar
  52. 52.
    Sarvilinna R, Huhtala HS, Puolakka TJ, Nevalainen JK, Pajamäki KJ (2003) Periprosthetic fractures in total hip arthroplasty: an epidemiologic study. Int Orthop 27(6):359–361PubMedCentralCrossRefPubMedGoogle Scholar
  53. 53.
    Shawen SB, Belmont PJ Jr, Klemme WR, Topoleski LD, Xenos JS, Orchowski JR (2003) Osteoporosis and anterior femoral notching in periprosthetic supracondylar femoral fractures: a biomechanical analysis. J Bone Joint Surg Am 85-A(1):115–121PubMedGoogle Scholar
  54. 54.
    Siegmeth A, Menth-Chiari W, Wozasek GE, Vécsei V (1998) Periprosthetic femur shaft fracture. Indications and outcome in 51 patients. Unfallchirurg 101(12):901–906CrossRefPubMedGoogle Scholar
  55. 55.
    Solarino G, Vicenti G, Moretti L, Abate A, Spinarelli A, Moretti B (2014) Interprosthetic femoral fractures-a challenge of treatment. A systematic review of the literature. Injury 45(2):362–368CrossRefPubMedGoogle Scholar
  56. 56.
    Stange R, Raschke MJ, Fuchs T (2011) Periprothetische Frakturen. Der Unfallchirurg 8(114):688–696CrossRefGoogle Scholar
  57. 57.
    Su ET, DeWal H, Di Cesare PE (2004) Periprosthetic femoral fractures above total knee replacements. J Am Acad Orthop Surg 12(1):12–20PubMedGoogle Scholar
  58. 58.
    Van der Merwe JM, Haddad FS, Duncan CP (2014) Field testing the unified classification system for periprosthetic fractures of the femur, tibia and patella in association with knee replacement: an international collaboration. Bone Joint J 96-B(12):1669–1673CrossRefPubMedGoogle Scholar
  59. 59.
    Van Elegem P, Blaimont P (1979) Femoral and acetabular fractures due to hip prosthesis. Acta Ortohop Belg 45(3):299–309Google Scholar
  60. 60.
    Whittaker RP, Sotos LN, Ralston EL (1974) Fractures of the femur about femoral endoprostheses. J Trauma 14(8):675–694CrossRefPubMedGoogle Scholar
  61. 61.
    Yasen AT, Haddad FS (2014) Periprosthetic fractures: bespoke solutions. Bone Joint J 96-B(11 Supple A):48–55CrossRefPubMedGoogle Scholar
  62. 62.
    Zehntner MK, Ganz R (1993) Internal fixation of supracondylar fractures after condylar total knee arthroplasty. Clin Orthop Relat Res 293:219–224PubMedGoogle Scholar

Copyright information

© SICOT aisbl 2015

Authors and Affiliations

  1. 1.Department of Trauma SurgeryMedical University of ViennaViennaAustria

Personalised recommendations