Diagnosis and Management of Intraoperative Fractures in Primary Total Hip Arthroplasty

Abstract

Intraoperative periprosthetic fractures are challenging complications that may affect implant stability and survivorship. Periprosthetic acetabular fractures are uncommon and infrequently are the focus of studies. Acetabular fractures are occasionally recognized after patients report unremitting groin pain weeks postoperatively. The widespread use of cementless acetabular cups might lead to higher number of fractures than is clinically detectable. Conversely, the incidence of intraoperative periprosthetic femoral fractures are more common and encompass a broad spectrum, ranging from a small cortical perforation to displaced fractures with an unstable prosthesis. Appropriate recognition, including mindfulness of preoperative patient and surgical risk factors, is critical to the successful management of acetabular and femoral complications. This comprehensive review article focuses on the incidence, patient and surgical risk factors, diagnosis, management, and clinical outcomes associated with intraoperative acetabular and femur fractures in primary total hip arthroplasty.

Management of Periprosthetic Acetabular Fractures

“…Acetabular implant designs are categorized as hemispherical, peripheral self-locking, and elliptical 4 (Fig. 1).…”

“…Women who are <65 years of age should undergo screening if the estimated 10-year fracture risk is equivalent to or greater than that of a 65-year-old Caucasian woman without additional risk factors 18 . However, the U.S. Preventive Services Task Force reported inconclusive data on which to recommend routine osteoporosis screening for men 4,18 . Although bisphosphonates are recommended as first-line pharmacologic treatment, the optimal intake of calcium and vitamin D is uncertain 18 .…”

“…Since periprosthetic acetabular fractures may be difficult to detect, having a high index of suspicion is critical 4 . The use of preoperative radiographic templating to estimate implant size is beneficial 4 . If the acetabular reamer and implant sizes required are much larger than the preoperative templating, or if the implant cannot be inserted with stability, a fracture may have occurred 4 .…”

“…The goals of intraoperative periprosthetic acetabular fracture care include fracture stabilization, mitigation of fracture propagation, preservation of component alignment and stability, and eventual fracture union 4,13 . For nondisplaced fractures with stable components, treatment may consist of additional acetabular screw fixation, rather than component removal, followed by standard postoperative rehabilitation regimens 4 . If the cup is unstable, the anterior and posterior columns should be inspected to determine further stabilization options.…”

“…T otal hip arthroplasty (THA) is one of the most effective and beneficial treatments in patients with hip osteoarthritis for improving pain, restoring function, and optimizing the patient's overall quality of life [1][2][3][4] . As a result, the need for primary THA has risen steadily over the last 2 decades and is expected to continue to rise exponentially in the next decade [4][5][6][7] . This is particularly important since the number of complications following THA is predicted to increase with the rise in procedure volume.…”