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.
Level of Evidence
Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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Acknowledgments
The authors thank Molly M. Moore for assistance with manuscript preparation and Christopher M. Brown BFA, MS for providing illustrations.
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Two of the authors certify that they (WNC, JAD) have received or may receive payments or benefits, during the study period, an amount of USD 10,000 to USD 100,000 from Stryker Orthopaedics (Mahwah, NJ, USA). One author (MN) is an employee of Stryker Orthopaedics.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.
Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
This work was performed at Indiana University Medical Center (Indianapolis, IN, USA), Sewickley Valley Hospital (Sewickley, PA, USA), and Stryker Orthopaedics (Mahwah, NJ, USA).
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Capello, W.N., D’Antonio, J.A. & Naughton, M. Periprosthetic Fractures Around a Cementless Hydroxyapatite-coated Implant: A New Fracture Pattern Is Described. Clin Orthop Relat Res 472, 604–610 (2014). https://doi.org/10.1007/s11999-013-3137-x
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DOI: https://doi.org/10.1007/s11999-013-3137-x