taunton.early.postoperative.femur.fracture.after.uncemented.collarless.primary.tha
TRANSCRIPT
8162019 Tauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha
httpslidepdfcomreaderfulltauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha 14
Early Postoperative Femur Fracture After Uncemented Collarless Primary
Total Hip Arthroplasty Characterization and Results of Treatment
Michael J Taunton MD a Lawrence D Dorr MD b William T Long MD bManish R Dastane MD b Daniel J Berry MD a
a Mayo Graduate School of Medicine Mayo Clinic Rochester Minnesotab Arthritis Institute Centinela Hospital Medical Center Inglewood California
a b s t r a c ta r t i c l e i n f o
Article historyReceived 27 January 2015
Accepted 20 May 2015
Available online xxxx
Keywords
postoperative
THA
uncemented
outcomes
primary
Thirty Vancouvertype B periprosthetic fractures occurred within 90 days of total hiparthroplastywere identi1047297edusing two institutional databases Twenty-eight of these fractures were of a stereotyped fracture pattern
consisting of a displaced fracture of the femoral neck including the lesser trochanter and a variable amount of
the proximal medial femoral cortex creating a roughly triangular fragment Time from operation until fracture
was 2ndash88 days (mean 28) Mechanism of injury was fall from standing height in 12 no de 1047297ned trauma in 11
stumble without fall in 5 and twisting motion in 2 Fracture treatment consisted of femoral revision in 24
fracture 1047297xation in two and nonoperative in four Of the 24 treated with revision 21 had healed fractures and
stable revision stems
copy 2015 Elsevier Inc All r ights reserved
As uncemented total hip arthroplasty (THA) has come into more
common use data from several national joint registries and other
sources have suggested that early periprosthetic femur fractures afterprimary uncemented THA are one of the most frequent early modes of
implant failure and one of the most common complications leading to
early revision [1ndash3] The purpose of this study was to characterize
early periprosthetic femur fractures after uncemented primary THA
with respect to fracture pattern frequency circumstances of occur-
rence and outcome of treatment The fractures uniquely strongly asso-
ciated with uncemented primary THA are the Vancouver Type B
fractures and hence these fractures are the focus of this report
Materials and Methods
Between January 1987 and December 2007 19271 consecutive pri-
mary total hip arthroplasties were performed at the authors rsquo two insti-
tutions of which 7447 were performed utilizing an uncemented
proximally porous coated collarless femoral component Over this
time period stems of many designs were implanted at the two institu-
tions and stem design was chosen at the discretion of the surgeon
The computerized databases of the authorsrsquo two institutions wereused to identify all periprosthetic femur fractures occurring within
90 days of implantation of an uncemented proximally porous coated
collarless femoral component between 1987 and 2007 Exclusion
criteria included patients with a previous surgical procedure to the
proximal femur or a previous proximal femur fracture The study was
approved by the Institutional Review Boards of both institutions
The preoperative postoperative fracture and latest followup radio-
graphs of allhips that sustained a fracture were evaluated by two of the
authors (DJB and MJT) Bone morphology was assessed on the preoper-
ative radiographs according to the criteria of Dorr [4ndash6] Fractures
were classi1047297ed according to the Vancouver system described by Duncan
and Masri [7] This classi1047297cation system has been validated and
shown to have high intraobserver and interobserver reliability [8]
At the authorsrsquo two institutions it is routine to obtain postoperative
anteroposterior and lateral radiographs immediatelyafter the operation
on theday of surgery All radiographs were con1047297rmed to have no visible
fracture on immediate postoperative radiographs
Operative reports and clinical notes were reviewed to correlate clin-
ical factors Patients with a fracture identi1047297ed intraoperatively were ex-
cluded Data from the early postoperative period were reviewed and
recorded including the patientsrsquo location at the time of fracture (hospi-
tal rehabilitation facility or at home) the patientsrsquo weight bearing sta-
tus rehabilitation protocol support used at the time of fracture (walker
cane or crutches) and activity at time of fracture event Clinical data re-
garding outcome of the fracture and its treatment were collected at the
time of most recent followup evaluation
The Journal of Arthroplasty xxx (2015) xxxndashxxx
Oneor more ofthe authors ofthis paper havedisclosedpotential orpertinentcon1047298icts
of interest which may include receipt of payment either direct or indirect institutional
support or association with an entity in the biomedical 1047297eld which may be perceived to
have potential con1047298ict of interest with this work For full disclosure statements refer to
httpdxdoiorg101016jarth201505044
Source of Funding There was no external funding for this study
ReprintrequestsDaniel J Berry MD Mayo Clinic200 First Street SWRochester MN
55905
httpdxdoiorg101016jarth201505044
0883-5403copy 2015 Elsevier Inc All rights reserved
Contents lists available at ScienceDirect
The Journal of Arthroplasty
j o u r n a l h o m e p a g e w w w a r t h r o p l a s t y j o u r n a l o r g
Please cite thisarticle as Taunton MJ et al Early Postoperative Femur Fracture After Uncemented Collarless Primary Total Hip Arthroplasty Char-acterization and Results of Tre J Arthroplasty (2015) httpdxdoiorg101016jarth201505044
8162019 Tauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha
httpslidepdfcomreaderfulltauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha 24
The 1047297xation of cemented stems after revision was assessed accord-
ing to the criteria of Harris et al [9] The 1047297xation of uncemented
stems after revision was assessed according to the method of Engh
and Massin [10]
Statistical Analysis
All statistical analyses were performed with two-tailed tests The
level of signi1047297cance was set at P b 005
Results
Vancouver type B femur fractures were identi1047297ed to have occurred
in the 1047297rst 90 days after THA in 30 hips (30 patients) among the 7447
hips for an incidence of 04 There were 18 females and 12 males
with a mean age of 63 years (range 25ndash84 years) The mean body
mass index was 31 (range 21ndash46) Arthroplasty approach was posterior
in 16 (minimally invasive in 5) anterior in 11 transtrochanteric in one
and two-incision minimally invasive in 2 Eleven fractures involved the
left hip and 19 involved the right hip The primary operative diagnosis
was osteoarthritis in 25 hips osteonecrosis of the femoral head in two
hips posttraumatic arthritis in two hips and rheumatoid arthritis in
onehip Fifteen patients had Dorr type ldquoArdquo proximal femoral bonemor-
phology and 15 had type ldquoBrdquo bone
There were four different stem types studied making up the 7447
stems The Hydroxyapatite Proxilock (Zimmer Warsaw Indiana) was
inserted in 662 pts with 11 fractures (16 fracture rate) APR (Zimmer
Warsaw IN) in 3422 pts with10 fractures (01 fracture rate) Omni1047298ex
(Stryker Kalamazoo MI) in 942 patients with 4 fractures (04 fracture
rate) Summit (Depuy USA) in 1208patients with 3 fractures(03 frac-
ture rate) and Secur-Fit Hydroxyapatite (Stryker Kalamazoo MI) in
1213 patients with 2 fractures (02 fracture rate)
The mean time between the arthroplasty and fracture was 28 days
(range 2ndash88 days) The mechanism of injury consisted of a fall from
standing height in 12 patients no de1047297ned trauma in 11 patients a trip
or stumble in 1047297ve patients and twisting at the hip in two patients At
time of fracture 20 patients were still using arm support to ambulate
Twelve patients were using a walker 7 were using crutches and 1was using a cane Nineteen patients had been instructed that they
could weight bear as tolerated on the operative limb at the time of frac-
ture and 11 had been instructed to be partial weight bearing with arm
support at the time of fracture
In 28 hips the femur fracture was of a stereotyped pattern consisting
of a fracture of the femoral neck and proximal medial femur which
exited through the medial cortex creating a roughly triangular fracture
fragment that included the lessertrochanter (Figs 1 and 2) Theaverage
distance below the lesser trochanter that the fracture exited the medial
cortex was 37 cm (range 0ndash11 cm) In two of these 28 hips in which
this same fracture pattern was con1047297rmed at the time of reoperation
there was notable sudden stem subsidence but the fracture lines were
not visible on the radiographs Two hips had Vancouver typeB proximal
femur fractures that exited through the lateral cortex below the level of the lesser trochanter rather than medially
Fracture treatment consisted of reoperation with femoral compo-
nent revision and fracture stabilization in 24 hips reoperation with
stem retention and fracture stabilization in 2 and nonoperative treat-
ment in 4 Twelve femoral components were revised to an extensively
porous coated uncemented stem 6 were revised to a 1047298uted-tapered
modular uncemented stem (Fig 2) 3 were exchanged for a larger
stem of the same design and three were revised to a cemented stem
The average duration of followup after fracture was 45 months
(range 3ndash219 months) The average preoperative Harris Hip score was
42 (range 13ndash67) This improved to an average postoperative Harris
Hip score of 76 (range 32ndash100) at latest followup
At latest followup the 4 femur fractures that were selected for non-
operative treatment had healed and the implants were radiographically
stable The 2 femurs that were selected for treatment with internal
1047297xation and stem retention also healed and the implants were
radiographically stable at latest followup Twenty-one of 24 fractures
treated with femoral component revision healed and had a stable
femoral component at latest followup Two of the 24 patients treated
with femoral revision developed prosthetic infection and had further
procedures (Fig 3) and one of the 24 patients treated with femoral
revision developed femoral component loosening and had another
femoral revision
Discussion
Early periprosthetic femur fracture after primary uncemented THA
recently has been shown to be a leading reason for early revision after
THA in large national joint registry databases [1ndash3] Little is known
about the fracture patterns clinical circumstances and results of treat-
ment when these fractures occur in contemporary practice Theprimary
purpose of this paper was to characterize the pattern and clinical
circumstances surrounding these fractures when they occur in conjunc-
tion with a commonly used class of uncemented femoral componentsmdashcollarless uncemented stems A secondary goal was to report early re-
sults of treatment
Twenty-eight of the 30 Vancouver type B fractures in this report
were of a single stereotypical pattern characterized by a separate frag-
ment of posterior medial cortical bone that included the lesser trochan-
ter We classi1047297ed these fractures as Vancouver type B periprosthetic
femur fractures rather than Vancouver A(L) fractures which are de-
scribed as avulsion fractures of the lesser trochanter The fractures de-
scribed in this report typically were associated with stem subsidence
and stem rotation to a relatively retroverted position Because the frac-
ture is usually associated with loss of implant 1047297xation in addition to
change in implant position acute reoperation typically is indicated
We hypothesize that early fractures of this pattern in association
with proximally porous coated uncemented femoral components may
Fig 1 (A) Immediate postoperative hip radiograph of a 71 year old woman after
uncemented THA (B) Radiograph 12 days postoperatively after the patient fell at home
while weight bearing as tolerated demonstrating fracture
2 MJ Taunton et al The Journal of Arthroplasty xxx (2015) xxxndash xxx
Pleasecite this article as Taunton MJet al Early Postoperative Femur Fracture After Uncemented CollarlessPrimary Total Hip Arthroplasty Char-acterization and Results of Tre J Arthroplasty (2015) httpdxdoiorg101016jarth201505044
8162019 Tauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha
httpslidepdfcomreaderfulltauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha 34
occur as the result of two separate circumstances In some cases these
postoperatively-recognized fractures may represent propagation and
displacement of an unrecognized minimally displaced intraoperative
crack In other cases these fractures may represent a new fracture
which occurs due to high axial and torsional loads being placed on the
uncemented implant as the result of a stumble or fall before the
wedge-shaped collarless implant has become osteointegrated into
the bone
The proximally porous coated tapered stems used by surgeons in
this study were all of the 3 dimensional taper designs The broaching
for these stems provides a slightly smaller space than the size of the ac-
tual stem As the 1047297nal stem is impacted hoop stresses occur The visco-
elastic nature of the bone allows for creep and stress relaxation of the
bone [11] As the press-1047297t lessens with relaxation the high roughness
of the porous surface the tapered design and perhaps 3-point 1047297xation
provide further initial stability The mechanical properties of these ta-pered stems then translate to working best in proximal femoral mor-
phology with these tapered medullary shapes allowing for maximal
implantndashbone contact For patients with weak proximal femoral bone
that does not provide reliable 1047297xation of an uncemented implant or
that may be at high risk for fracture cemented femoral component 1047297x-
ation with optimal implant designs can provide a high rate of success
Rapid mobilization of patients with early full weight bearing has be-
come common place and with early mobilization in the postoperative
period patients may be more likely to fall stumble or otherwise place
very high loads on the hip leading to a displaced fracture Hip
arthroplasty through smaller incisions has become common and small-
er incisions may make it dif 1047297cult for a surgeon to identify an intraoper-
ative fracture and treat it intraoperatively
In most cases in this report the fracture wastreated with reoperationconsisting of femoral component revision and fracture stabilization
with cerclage because in most cases the femoral component had lost
1047297xation subsided andor become retroverted as a consequence of
these fractures Two cases were successfully treated withfracture stabi-
lization without revision Intraoperatively it is essential to assess stem
stability and unless the stem is unquestionably stable axially and
rotationally the stem should be revised especially in this early postop-
erative circumstance before the stem is bone ingrown In the few cases
in this report in which the implant appeared to remain stable and in a
satisfactory position nonoperative treatment was successful The
early outcome of fracture treatment was favorable in the majority of
these 30 hips Nevertheless it is important to emphasize that all
patients suffered the morbidity associated with either operative or
nonoperative treatment of the fracture and in a several patients the
Fig 2 (A)Immediate postoperative radiographof an 84 yearold manafteruncemented THA(B) Radiograph 27 dayspost-operatively after thepatient hadincreasedpainat rehabilitation
facility while using a walker ambulating weight bearing as tolerated (C) Radiograph after revision to a 1047298uted tapered modular stem
Fig 3 (A) Immediate postoperative hip radiograph of a 70 year old woman after
uncemented THA (B) Radiograph 10 days postoperatively demonstrating periprosthetic
fracture and hip dislocation (C) Radiograph after revision to 1047298uted tapered stem
(D) Radiograph after component resection for infection following revision operation
3MJ Taunton et al The Journal of Arthroplasty xxx (2015) xxxndash xxx
Please cite thisarticle as Taunton MJ et al Early Postoperative Femur Fracture After Uncemented Collarless Primary Total Hip Arthroplasty Char-acterization and Results of Tre J Arthroplasty (2015) httpdxdoiorg101016jarth201505044
8162019 Tauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha
httpslidepdfcomreaderfulltauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha 44
fracture was the beginning of a cycle of further complicationsleading to
notable morbidity
By making surgeons aware of clinical circumstances associated with
early periprosthetic femur fracture the authors hope some such frac-
tures may be avoided in the future Careful consideration may be
given to the indications for use of these categories of femoral compo-
nents in patients considered at high risk for fracture due to poor bone
quality Selected patients so treated but considered at higher risk for
fracture may be treated with prophylactic intraoperative cerclage with
a wire or cable just above the lessertrochanter Thorough intraoperative
scrutiny of the femoral neck after implant placement may identify some
nondisplaced fractures and allow intraoperative treatment with
cerclage 1047297xation Careful consideration may be given to judicious use
of arm support for a period of time after surgery in patients at risk for
a stumble or fall which might precipitate a displaced fracture And1047297nal-
ly patient education about fracture risk may encourage caution to avoid
circumstances that could lead to stumble or fall in the early postopera-
tive time period
References
1 Havelin LI The Norwegian Joint Registry Bull Hosp Jt Dis 199958(3)1392 National Joint Registry forEngland andWales 9thannual report2012 [httpwwwhqip
orgukassetsNCAPOP-LibraryNCAPOP-2012-13NJR-9th-Annual-Report-2012pdf ]3 Australian Orthopaedic Association National Joint Replacement Registry annual re-
port 2014 [httpaoanjrrdmacadelaideeduaudocuments10180172286Annual20Report202014]
4 Dorr LD Absatz M Gruen TA et al Anatomic porous replacement hip arthroplasty1047297rst 100 consecutive cases Semin Arthroplasty 19901(1)77
5 Dorr LD Faugere MC Mackel AM et al Structural and cellular assessment of bone
quality of proximal femur Bone 199314(3)2316 Dossick PH Dorr LD Gruen T Saberi MT Techniques for pre-operative planning and
post-operative evaluation of non-cemented hip arthroplasty Tech Orthop 1991617 DuncanCP MasriBAFractures ofthe femurafter hipreplacementInstrCourse Lect1995442938 Brady OHGarbuzDS Masri BAet alThe reliabilityand validityof theVancouver clas-
si1047297cation of femoral fractures after hip replacement J Arthroplasty 200015(1)599 Harris WH McCarthy Jr JC ONeill DA Femoral component loosening using contem-
porary techniques of femoral cement 1047297xation J Bone Joint SurgAm 198264(7)106310 Engh CA Massin P Cementless total hip arthroplasty using the anatomic medullary
lockingstem Resultsusing a survivorship analysis ClinOrthop Relat Res 1989(249)14111 Mallory TH Head WC Lombardi Jr AV Tapered design for the cementless total hip
arthroplasty femoral component Clin Orthop Relat Res 1997433172
4 MJ Taunton et al The Journal of Arthroplasty xxx (2015) xxxndash xxx
Pleasecite this article as Taunton MJet al Early Postoperative Femur Fracture After Uncemented CollarlessPrimary Total Hip Arthroplasty Char-acterization and Results of Tre J Arthroplasty (2015) httpdxdoiorg101016jarth201505044
8162019 Tauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha
httpslidepdfcomreaderfulltauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha 24
The 1047297xation of cemented stems after revision was assessed accord-
ing to the criteria of Harris et al [9] The 1047297xation of uncemented
stems after revision was assessed according to the method of Engh
and Massin [10]
Statistical Analysis
All statistical analyses were performed with two-tailed tests The
level of signi1047297cance was set at P b 005
Results
Vancouver type B femur fractures were identi1047297ed to have occurred
in the 1047297rst 90 days after THA in 30 hips (30 patients) among the 7447
hips for an incidence of 04 There were 18 females and 12 males
with a mean age of 63 years (range 25ndash84 years) The mean body
mass index was 31 (range 21ndash46) Arthroplasty approach was posterior
in 16 (minimally invasive in 5) anterior in 11 transtrochanteric in one
and two-incision minimally invasive in 2 Eleven fractures involved the
left hip and 19 involved the right hip The primary operative diagnosis
was osteoarthritis in 25 hips osteonecrosis of the femoral head in two
hips posttraumatic arthritis in two hips and rheumatoid arthritis in
onehip Fifteen patients had Dorr type ldquoArdquo proximal femoral bonemor-
phology and 15 had type ldquoBrdquo bone
There were four different stem types studied making up the 7447
stems The Hydroxyapatite Proxilock (Zimmer Warsaw Indiana) was
inserted in 662 pts with 11 fractures (16 fracture rate) APR (Zimmer
Warsaw IN) in 3422 pts with10 fractures (01 fracture rate) Omni1047298ex
(Stryker Kalamazoo MI) in 942 patients with 4 fractures (04 fracture
rate) Summit (Depuy USA) in 1208patients with 3 fractures(03 frac-
ture rate) and Secur-Fit Hydroxyapatite (Stryker Kalamazoo MI) in
1213 patients with 2 fractures (02 fracture rate)
The mean time between the arthroplasty and fracture was 28 days
(range 2ndash88 days) The mechanism of injury consisted of a fall from
standing height in 12 patients no de1047297ned trauma in 11 patients a trip
or stumble in 1047297ve patients and twisting at the hip in two patients At
time of fracture 20 patients were still using arm support to ambulate
Twelve patients were using a walker 7 were using crutches and 1was using a cane Nineteen patients had been instructed that they
could weight bear as tolerated on the operative limb at the time of frac-
ture and 11 had been instructed to be partial weight bearing with arm
support at the time of fracture
In 28 hips the femur fracture was of a stereotyped pattern consisting
of a fracture of the femoral neck and proximal medial femur which
exited through the medial cortex creating a roughly triangular fracture
fragment that included the lessertrochanter (Figs 1 and 2) Theaverage
distance below the lesser trochanter that the fracture exited the medial
cortex was 37 cm (range 0ndash11 cm) In two of these 28 hips in which
this same fracture pattern was con1047297rmed at the time of reoperation
there was notable sudden stem subsidence but the fracture lines were
not visible on the radiographs Two hips had Vancouver typeB proximal
femur fractures that exited through the lateral cortex below the level of the lesser trochanter rather than medially
Fracture treatment consisted of reoperation with femoral compo-
nent revision and fracture stabilization in 24 hips reoperation with
stem retention and fracture stabilization in 2 and nonoperative treat-
ment in 4 Twelve femoral components were revised to an extensively
porous coated uncemented stem 6 were revised to a 1047298uted-tapered
modular uncemented stem (Fig 2) 3 were exchanged for a larger
stem of the same design and three were revised to a cemented stem
The average duration of followup after fracture was 45 months
(range 3ndash219 months) The average preoperative Harris Hip score was
42 (range 13ndash67) This improved to an average postoperative Harris
Hip score of 76 (range 32ndash100) at latest followup
At latest followup the 4 femur fractures that were selected for non-
operative treatment had healed and the implants were radiographically
stable The 2 femurs that were selected for treatment with internal
1047297xation and stem retention also healed and the implants were
radiographically stable at latest followup Twenty-one of 24 fractures
treated with femoral component revision healed and had a stable
femoral component at latest followup Two of the 24 patients treated
with femoral revision developed prosthetic infection and had further
procedures (Fig 3) and one of the 24 patients treated with femoral
revision developed femoral component loosening and had another
femoral revision
Discussion
Early periprosthetic femur fracture after primary uncemented THA
recently has been shown to be a leading reason for early revision after
THA in large national joint registry databases [1ndash3] Little is known
about the fracture patterns clinical circumstances and results of treat-
ment when these fractures occur in contemporary practice Theprimary
purpose of this paper was to characterize the pattern and clinical
circumstances surrounding these fractures when they occur in conjunc-
tion with a commonly used class of uncemented femoral componentsmdashcollarless uncemented stems A secondary goal was to report early re-
sults of treatment
Twenty-eight of the 30 Vancouver type B fractures in this report
were of a single stereotypical pattern characterized by a separate frag-
ment of posterior medial cortical bone that included the lesser trochan-
ter We classi1047297ed these fractures as Vancouver type B periprosthetic
femur fractures rather than Vancouver A(L) fractures which are de-
scribed as avulsion fractures of the lesser trochanter The fractures de-
scribed in this report typically were associated with stem subsidence
and stem rotation to a relatively retroverted position Because the frac-
ture is usually associated with loss of implant 1047297xation in addition to
change in implant position acute reoperation typically is indicated
We hypothesize that early fractures of this pattern in association
with proximally porous coated uncemented femoral components may
Fig 1 (A) Immediate postoperative hip radiograph of a 71 year old woman after
uncemented THA (B) Radiograph 12 days postoperatively after the patient fell at home
while weight bearing as tolerated demonstrating fracture
2 MJ Taunton et al The Journal of Arthroplasty xxx (2015) xxxndash xxx
Pleasecite this article as Taunton MJet al Early Postoperative Femur Fracture After Uncemented CollarlessPrimary Total Hip Arthroplasty Char-acterization and Results of Tre J Arthroplasty (2015) httpdxdoiorg101016jarth201505044
8162019 Tauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha
httpslidepdfcomreaderfulltauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha 34
occur as the result of two separate circumstances In some cases these
postoperatively-recognized fractures may represent propagation and
displacement of an unrecognized minimally displaced intraoperative
crack In other cases these fractures may represent a new fracture
which occurs due to high axial and torsional loads being placed on the
uncemented implant as the result of a stumble or fall before the
wedge-shaped collarless implant has become osteointegrated into
the bone
The proximally porous coated tapered stems used by surgeons in
this study were all of the 3 dimensional taper designs The broaching
for these stems provides a slightly smaller space than the size of the ac-
tual stem As the 1047297nal stem is impacted hoop stresses occur The visco-
elastic nature of the bone allows for creep and stress relaxation of the
bone [11] As the press-1047297t lessens with relaxation the high roughness
of the porous surface the tapered design and perhaps 3-point 1047297xation
provide further initial stability The mechanical properties of these ta-pered stems then translate to working best in proximal femoral mor-
phology with these tapered medullary shapes allowing for maximal
implantndashbone contact For patients with weak proximal femoral bone
that does not provide reliable 1047297xation of an uncemented implant or
that may be at high risk for fracture cemented femoral component 1047297x-
ation with optimal implant designs can provide a high rate of success
Rapid mobilization of patients with early full weight bearing has be-
come common place and with early mobilization in the postoperative
period patients may be more likely to fall stumble or otherwise place
very high loads on the hip leading to a displaced fracture Hip
arthroplasty through smaller incisions has become common and small-
er incisions may make it dif 1047297cult for a surgeon to identify an intraoper-
ative fracture and treat it intraoperatively
In most cases in this report the fracture wastreated with reoperationconsisting of femoral component revision and fracture stabilization
with cerclage because in most cases the femoral component had lost
1047297xation subsided andor become retroverted as a consequence of
these fractures Two cases were successfully treated withfracture stabi-
lization without revision Intraoperatively it is essential to assess stem
stability and unless the stem is unquestionably stable axially and
rotationally the stem should be revised especially in this early postop-
erative circumstance before the stem is bone ingrown In the few cases
in this report in which the implant appeared to remain stable and in a
satisfactory position nonoperative treatment was successful The
early outcome of fracture treatment was favorable in the majority of
these 30 hips Nevertheless it is important to emphasize that all
patients suffered the morbidity associated with either operative or
nonoperative treatment of the fracture and in a several patients the
Fig 2 (A)Immediate postoperative radiographof an 84 yearold manafteruncemented THA(B) Radiograph 27 dayspost-operatively after thepatient hadincreasedpainat rehabilitation
facility while using a walker ambulating weight bearing as tolerated (C) Radiograph after revision to a 1047298uted tapered modular stem
Fig 3 (A) Immediate postoperative hip radiograph of a 70 year old woman after
uncemented THA (B) Radiograph 10 days postoperatively demonstrating periprosthetic
fracture and hip dislocation (C) Radiograph after revision to 1047298uted tapered stem
(D) Radiograph after component resection for infection following revision operation
3MJ Taunton et al The Journal of Arthroplasty xxx (2015) xxxndash xxx
Please cite thisarticle as Taunton MJ et al Early Postoperative Femur Fracture After Uncemented Collarless Primary Total Hip Arthroplasty Char-acterization and Results of Tre J Arthroplasty (2015) httpdxdoiorg101016jarth201505044
8162019 Tauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha
httpslidepdfcomreaderfulltauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha 44
fracture was the beginning of a cycle of further complicationsleading to
notable morbidity
By making surgeons aware of clinical circumstances associated with
early periprosthetic femur fracture the authors hope some such frac-
tures may be avoided in the future Careful consideration may be
given to the indications for use of these categories of femoral compo-
nents in patients considered at high risk for fracture due to poor bone
quality Selected patients so treated but considered at higher risk for
fracture may be treated with prophylactic intraoperative cerclage with
a wire or cable just above the lessertrochanter Thorough intraoperative
scrutiny of the femoral neck after implant placement may identify some
nondisplaced fractures and allow intraoperative treatment with
cerclage 1047297xation Careful consideration may be given to judicious use
of arm support for a period of time after surgery in patients at risk for
a stumble or fall which might precipitate a displaced fracture And1047297nal-
ly patient education about fracture risk may encourage caution to avoid
circumstances that could lead to stumble or fall in the early postopera-
tive time period
References
1 Havelin LI The Norwegian Joint Registry Bull Hosp Jt Dis 199958(3)1392 National Joint Registry forEngland andWales 9thannual report2012 [httpwwwhqip
orgukassetsNCAPOP-LibraryNCAPOP-2012-13NJR-9th-Annual-Report-2012pdf ]3 Australian Orthopaedic Association National Joint Replacement Registry annual re-
port 2014 [httpaoanjrrdmacadelaideeduaudocuments10180172286Annual20Report202014]
4 Dorr LD Absatz M Gruen TA et al Anatomic porous replacement hip arthroplasty1047297rst 100 consecutive cases Semin Arthroplasty 19901(1)77
5 Dorr LD Faugere MC Mackel AM et al Structural and cellular assessment of bone
quality of proximal femur Bone 199314(3)2316 Dossick PH Dorr LD Gruen T Saberi MT Techniques for pre-operative planning and
post-operative evaluation of non-cemented hip arthroplasty Tech Orthop 1991617 DuncanCP MasriBAFractures ofthe femurafter hipreplacementInstrCourse Lect1995442938 Brady OHGarbuzDS Masri BAet alThe reliabilityand validityof theVancouver clas-
si1047297cation of femoral fractures after hip replacement J Arthroplasty 200015(1)599 Harris WH McCarthy Jr JC ONeill DA Femoral component loosening using contem-
porary techniques of femoral cement 1047297xation J Bone Joint SurgAm 198264(7)106310 Engh CA Massin P Cementless total hip arthroplasty using the anatomic medullary
lockingstem Resultsusing a survivorship analysis ClinOrthop Relat Res 1989(249)14111 Mallory TH Head WC Lombardi Jr AV Tapered design for the cementless total hip
arthroplasty femoral component Clin Orthop Relat Res 1997433172
4 MJ Taunton et al The Journal of Arthroplasty xxx (2015) xxxndash xxx
Pleasecite this article as Taunton MJet al Early Postoperative Femur Fracture After Uncemented CollarlessPrimary Total Hip Arthroplasty Char-acterization and Results of Tre J Arthroplasty (2015) httpdxdoiorg101016jarth201505044
8162019 Tauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha
httpslidepdfcomreaderfulltauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha 34
occur as the result of two separate circumstances In some cases these
postoperatively-recognized fractures may represent propagation and
displacement of an unrecognized minimally displaced intraoperative
crack In other cases these fractures may represent a new fracture
which occurs due to high axial and torsional loads being placed on the
uncemented implant as the result of a stumble or fall before the
wedge-shaped collarless implant has become osteointegrated into
the bone
The proximally porous coated tapered stems used by surgeons in
this study were all of the 3 dimensional taper designs The broaching
for these stems provides a slightly smaller space than the size of the ac-
tual stem As the 1047297nal stem is impacted hoop stresses occur The visco-
elastic nature of the bone allows for creep and stress relaxation of the
bone [11] As the press-1047297t lessens with relaxation the high roughness
of the porous surface the tapered design and perhaps 3-point 1047297xation
provide further initial stability The mechanical properties of these ta-pered stems then translate to working best in proximal femoral mor-
phology with these tapered medullary shapes allowing for maximal
implantndashbone contact For patients with weak proximal femoral bone
that does not provide reliable 1047297xation of an uncemented implant or
that may be at high risk for fracture cemented femoral component 1047297x-
ation with optimal implant designs can provide a high rate of success
Rapid mobilization of patients with early full weight bearing has be-
come common place and with early mobilization in the postoperative
period patients may be more likely to fall stumble or otherwise place
very high loads on the hip leading to a displaced fracture Hip
arthroplasty through smaller incisions has become common and small-
er incisions may make it dif 1047297cult for a surgeon to identify an intraoper-
ative fracture and treat it intraoperatively
In most cases in this report the fracture wastreated with reoperationconsisting of femoral component revision and fracture stabilization
with cerclage because in most cases the femoral component had lost
1047297xation subsided andor become retroverted as a consequence of
these fractures Two cases were successfully treated withfracture stabi-
lization without revision Intraoperatively it is essential to assess stem
stability and unless the stem is unquestionably stable axially and
rotationally the stem should be revised especially in this early postop-
erative circumstance before the stem is bone ingrown In the few cases
in this report in which the implant appeared to remain stable and in a
satisfactory position nonoperative treatment was successful The
early outcome of fracture treatment was favorable in the majority of
these 30 hips Nevertheless it is important to emphasize that all
patients suffered the morbidity associated with either operative or
nonoperative treatment of the fracture and in a several patients the
Fig 2 (A)Immediate postoperative radiographof an 84 yearold manafteruncemented THA(B) Radiograph 27 dayspost-operatively after thepatient hadincreasedpainat rehabilitation
facility while using a walker ambulating weight bearing as tolerated (C) Radiograph after revision to a 1047298uted tapered modular stem
Fig 3 (A) Immediate postoperative hip radiograph of a 70 year old woman after
uncemented THA (B) Radiograph 10 days postoperatively demonstrating periprosthetic
fracture and hip dislocation (C) Radiograph after revision to 1047298uted tapered stem
(D) Radiograph after component resection for infection following revision operation
3MJ Taunton et al The Journal of Arthroplasty xxx (2015) xxxndash xxx
Please cite thisarticle as Taunton MJ et al Early Postoperative Femur Fracture After Uncemented Collarless Primary Total Hip Arthroplasty Char-acterization and Results of Tre J Arthroplasty (2015) httpdxdoiorg101016jarth201505044
8162019 Tauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha
httpslidepdfcomreaderfulltauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha 44
fracture was the beginning of a cycle of further complicationsleading to
notable morbidity
By making surgeons aware of clinical circumstances associated with
early periprosthetic femur fracture the authors hope some such frac-
tures may be avoided in the future Careful consideration may be
given to the indications for use of these categories of femoral compo-
nents in patients considered at high risk for fracture due to poor bone
quality Selected patients so treated but considered at higher risk for
fracture may be treated with prophylactic intraoperative cerclage with
a wire or cable just above the lessertrochanter Thorough intraoperative
scrutiny of the femoral neck after implant placement may identify some
nondisplaced fractures and allow intraoperative treatment with
cerclage 1047297xation Careful consideration may be given to judicious use
of arm support for a period of time after surgery in patients at risk for
a stumble or fall which might precipitate a displaced fracture And1047297nal-
ly patient education about fracture risk may encourage caution to avoid
circumstances that could lead to stumble or fall in the early postopera-
tive time period
References
1 Havelin LI The Norwegian Joint Registry Bull Hosp Jt Dis 199958(3)1392 National Joint Registry forEngland andWales 9thannual report2012 [httpwwwhqip
orgukassetsNCAPOP-LibraryNCAPOP-2012-13NJR-9th-Annual-Report-2012pdf ]3 Australian Orthopaedic Association National Joint Replacement Registry annual re-
port 2014 [httpaoanjrrdmacadelaideeduaudocuments10180172286Annual20Report202014]
4 Dorr LD Absatz M Gruen TA et al Anatomic porous replacement hip arthroplasty1047297rst 100 consecutive cases Semin Arthroplasty 19901(1)77
5 Dorr LD Faugere MC Mackel AM et al Structural and cellular assessment of bone
quality of proximal femur Bone 199314(3)2316 Dossick PH Dorr LD Gruen T Saberi MT Techniques for pre-operative planning and
post-operative evaluation of non-cemented hip arthroplasty Tech Orthop 1991617 DuncanCP MasriBAFractures ofthe femurafter hipreplacementInstrCourse Lect1995442938 Brady OHGarbuzDS Masri BAet alThe reliabilityand validityof theVancouver clas-
si1047297cation of femoral fractures after hip replacement J Arthroplasty 200015(1)599 Harris WH McCarthy Jr JC ONeill DA Femoral component loosening using contem-
porary techniques of femoral cement 1047297xation J Bone Joint SurgAm 198264(7)106310 Engh CA Massin P Cementless total hip arthroplasty using the anatomic medullary
lockingstem Resultsusing a survivorship analysis ClinOrthop Relat Res 1989(249)14111 Mallory TH Head WC Lombardi Jr AV Tapered design for the cementless total hip
arthroplasty femoral component Clin Orthop Relat Res 1997433172
4 MJ Taunton et al The Journal of Arthroplasty xxx (2015) xxxndash xxx
Pleasecite this article as Taunton MJet al Early Postoperative Femur Fracture After Uncemented CollarlessPrimary Total Hip Arthroplasty Char-acterization and Results of Tre J Arthroplasty (2015) httpdxdoiorg101016jarth201505044
8162019 Tauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha
httpslidepdfcomreaderfulltauntonearlypostoperativefemurfractureafteruncementedcollarlessprimarytha 44
fracture was the beginning of a cycle of further complicationsleading to
notable morbidity
By making surgeons aware of clinical circumstances associated with
early periprosthetic femur fracture the authors hope some such frac-
tures may be avoided in the future Careful consideration may be
given to the indications for use of these categories of femoral compo-
nents in patients considered at high risk for fracture due to poor bone
quality Selected patients so treated but considered at higher risk for
fracture may be treated with prophylactic intraoperative cerclage with
a wire or cable just above the lessertrochanter Thorough intraoperative
scrutiny of the femoral neck after implant placement may identify some
nondisplaced fractures and allow intraoperative treatment with
cerclage 1047297xation Careful consideration may be given to judicious use
of arm support for a period of time after surgery in patients at risk for
a stumble or fall which might precipitate a displaced fracture And1047297nal-
ly patient education about fracture risk may encourage caution to avoid
circumstances that could lead to stumble or fall in the early postopera-
tive time period
References
1 Havelin LI The Norwegian Joint Registry Bull Hosp Jt Dis 199958(3)1392 National Joint Registry forEngland andWales 9thannual report2012 [httpwwwhqip
orgukassetsNCAPOP-LibraryNCAPOP-2012-13NJR-9th-Annual-Report-2012pdf ]3 Australian Orthopaedic Association National Joint Replacement Registry annual re-
port 2014 [httpaoanjrrdmacadelaideeduaudocuments10180172286Annual20Report202014]
4 Dorr LD Absatz M Gruen TA et al Anatomic porous replacement hip arthroplasty1047297rst 100 consecutive cases Semin Arthroplasty 19901(1)77
5 Dorr LD Faugere MC Mackel AM et al Structural and cellular assessment of bone
quality of proximal femur Bone 199314(3)2316 Dossick PH Dorr LD Gruen T Saberi MT Techniques for pre-operative planning and
post-operative evaluation of non-cemented hip arthroplasty Tech Orthop 1991617 DuncanCP MasriBAFractures ofthe femurafter hipreplacementInstrCourse Lect1995442938 Brady OHGarbuzDS Masri BAet alThe reliabilityand validityof theVancouver clas-
si1047297cation of femoral fractures after hip replacement J Arthroplasty 200015(1)599 Harris WH McCarthy Jr JC ONeill DA Femoral component loosening using contem-
porary techniques of femoral cement 1047297xation J Bone Joint SurgAm 198264(7)106310 Engh CA Massin P Cementless total hip arthroplasty using the anatomic medullary
lockingstem Resultsusing a survivorship analysis ClinOrthop Relat Res 1989(249)14111 Mallory TH Head WC Lombardi Jr AV Tapered design for the cementless total hip
arthroplasty femoral component Clin Orthop Relat Res 1997433172
4 MJ Taunton et al The Journal of Arthroplasty xxx (2015) xxxndash xxx
Pleasecite this article as Taunton MJet al Early Postoperative Femur Fracture After Uncemented CollarlessPrimary Total Hip Arthroplasty Char-acterization and Results of Tre J Arthroplasty (2015) httpdxdoiorg101016jarth201505044