Risk factors in treatment of periprosthetic fractures


Although primary total hip replacement (THR) has, in general, excellent long-term outcomes, periprosthetic femoral fracture (PPFF) after THR is a serious complication. The treatment of PPFF is clinically challenging with high mortality, morbidity, and associated costs. In recognizing the risk factors in treatment of PPFF, surgeons can try to optimize the treatment and contribute to society with efficient and effective patient care. In this article, the general risk factors in treating PPFF patients are discussed along with the ways to ameliorate them.


Epidemiology

THR has become one of the most successful orthopedic interventions over the last decades. The excellent results have led to an expanded indication to include both younger and more elderly adults [1]. Younger patients tend to be more active and more elderly patients tend to have poorer bone quality and increased comorbidity; such factors result in the increased probability of implant loosening and increase the chance of PPFF [2–4]. Meanwhile, with the increasing longevity of the population in general, patients with hip replacement can also be expected to live longer, which means that the implants will be in service for longer, and therefore have an increased likelihood of failing [1, 5]. This has been demonstrated by data from a Swedish registry; in the Scottish and Finnish populations this has been less clear [5–7].

Concerning such discrepancies in different epidemiological studies, Cao Li, president of the Chinese Hip Society and director of the First Affiliated Hospital Xinjiang University, Urumqi, China, reminds us that, "Epidemiological studies are empirical studies. Many of them may be simply too small to give us a definitive answer. Currently, studies on intraoperative risk factors of periprosthetic acetabular fractures are still lacking."

Cao Li

Professor
President of the Chinese Hip Society and director of the First Affiliated Hospital Xinjiang University
Urumqi, China

Baochao Ji

Associate professor
First Affiliated Hospital of Xinjiang Medical University
Urumqi, Xinjiang, China


How does the outcome of revision THR compare with primary THR?

When compared with primary THRs, the risk of suffering a PPFF is much higher in revision THR, although not many studies have directly compared the incidences of PPFF between primary and revision THR. Lindahl et al reported an incidence of 0.4% in primary and 2.1% in revision THR, and Kavanagh estimated the incidence to be 1% after primary total hip arthroplasty (THA) and 4.2% after revision THA [3, 8]. In assessing 32,644 primary and 5,417 revision THR cases from 1969 to 2011 in the United States, Abdel et al showed a large increase in the incidence of intraoperative fractures in revision THR: from 1.7% for primary THR to 12.3% for revision THR. In the same study, the cumulative probability of suffering a PPFF was 0.8% for primary THR and 3.8% for revision THR at five years [1, 9] (Table 1). Meek et al came to similar results using data from a Scottish national database between 1997 and 2008 (52,136 primary THR, 8,726 revision THR); they reported a hazard ratio of revision THR being 4.4 times more likely to end in a PPFF than primary THR [5].

The mortality following surgical treatment for PPFF ranged widely from 3.3% to 34% at one year [10–13].

Table 1. Risk of fracture after primary versus revision THR. Data summarized from
1) Abdel MP, Watts CD, Houdek MT, et al. Epidemiology of periprosthetic fracture of the femur in 32 644 primary total hip arthroplasties: a 40-year experience. Bone Joint J. 2016 Apr;98-b(4):46–467,
2) Abdel MP, Houdek MT, Watts CD, et al. Epidemiology of periprosthetic femoral fractures in 5417 revision total hip arthroplasties: a 40-year experience. Bone Joint J. 2016 Apr;98-b(4):468–474, and
3) Meek RM, Norwood T, Smith R, et al. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br. 2011 Jan;93(1):96–101.

Injury mechanism

PPFFs often (75–84%) occur after minor trauma or ground-level falls, compared to “spontaneous” fracture (8–18%) after primary THR (the incidence of the latter can be as high as 37–50% after revision THR) [14, 15]. In a study by Bethea et al, it was shown that 75% of the patients treated for PPFF had prefracture radiographic evidence of loosening. The authors explained that, “As loosening progresses, a fibrous layer develops between the bone and the cement, increased movement at this interface results in further bone resorption.” [4]

While the fracture itself is easy to diagnose, component loosening often remains unrecognized. The history the preinjury symptoms and the knowledge of the mechanism of failure may shed light on the condition of the implants; both are therefore important for treatment decision-making. For example, spontaneous fractures in the early postoperative period should raise clinical suspicion for an unrecognized intraoperative fracture, whereas late spontaneous fractures are often associated with underlying osteolysis [15]. In case of low-energy trauma events, patients often do not provide any traumatic history but describe a gradually increasing pain [16–18]. A prodrome of thigh pain, especially start-up pain, is suggestive of a loose femoral component that may have been a contributing factor to the fracture.

 

What are the risk factors?

Surgical management of PPFF is technically demanding, requiring skills in both arthroplasty and trauma. Implant loosening, compromised surgical bed, osteolysis, osteoporosis, and concurrent infection are some of the challenges that often confront the surgeons. Understanding and identifying the perioperative risk factors is a key step towards reducing complications and will help with the treatment decision.


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  • What are the risk factors?
  • Patient-related risk factors: gender, age, and comorbidity
  • Implant-related risk factors: cemented versus uncemented implants
  • How can surgeon-related risk be reduced when treating PPFF?
  • Vancouver classification system
  • Surgeon-related risk: Unidentified periprosthetic joint infection
  • Postoperative risk factors
  • Conclusion
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Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):

Baochao Ji

Associate professor
First Affiliated Hospital of Xinjiang Medical University
Urumqi, Xinjiang, China

Cao Li

Professor
President of the Chinese Hip Society and director of the First Affiliated Hospital Xinjiang University
Urumqi, China

Karl Stoffel

Chief Physician
Bethesda Hospital
University Hospital Basel, Switzerland

Luigi Zagra

Head of the Hip Department
IRCCS Galeazzi Orthopaedic Institute, Milan,
and Past President of the European and Italian Hip Societies, Italy

This issue was written by Maio Chen, AO Innovation Translation Center, Clinical Science, Switzerland.

 

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