Periprosthetic stress fracture around a well-fixed type 2B short uncemented stem

Abstract

Despite the theoretical advantages of uncemented short stems, postoperative thigh pain is still matter of concern and can be attributed to different causes. We report a peculiar case of a stress fracture around a short cementless stem with cervico-metaphyseal fixation in an otherwise healthy patient. We implanted a MiniHipTM stem in a 43 year-old male professional golf player for the treatment of primary osteoarthritis using a ceramic on ceramic bearing. Against medical advice, the patient started to play soccer at the 4th postoperative month and was completely asymptomatic to that extent; but at 8 months follow-up and without a history of trauma he started complaining about progressive hip pain. After ruling out infection and loosening, histological analysis from a bone biopsy confirmed the diagnosis of stress fracture. Although revision surgery was initially scheduled, pain started to decrease gradually with protected weight-bearing (crutches) and disappeared around the first postoperative year, remaining the patient asymptomatic at 2 and half years of follow-up, with radiographs depicting a healed fracture with a hypertrophic callus. We encourage surgeons to be aware of the existence of periprosthetic stress fractures as a source of thigh pain (sometimes intractable), and despite being infrequent, they should always be contemplated, providing that these cases can be managed conservatively with rest and limited weight-bearing. After this uncommon case, we suggest to align the stem in order to equally distribute loads onto the medial calcar and the lateral femoral cortical.

Fifty-six percent of proximal femoral cortical hypertrophies 6 to 10 years after Total hip arthroplasty with a short Cementless curved hip stem – a cause for concern?

“…This finding supports our assumption, that the present distal femoral cortical hypertrophies might be attributable to bone remodeling with pronounced distal load transfer. However, surgeons should be aware that asymptomatic CHs should be distinguished from symptomatic CHs presenting with thigh pain because stress fractures around a short cementless stem without trauma have been reported in rare cases [29]. Stem survival was good in the present study with 93.7% after 8.6 years for the endpoint all stem revisions comparing well to other trochanter sparing stem designs with survival rates of 90 to 98% after 7 years [12].…”

Late Periprosthetic Femoral Stress Fracture Associated with Extra-articular Deformity in a Patient with Fibrous Dysplasia

“…T here are very few reports on stress fractures around wellfixed femoral stems and even less around cemented stems. Most cases had been attributed to poor bone quality, alterations of bone metabolism, bisphosphonate therapy, or a specific type of implant failure 11,[20][21][22][23] . Table I summarizes the most important findings of reports of stress fractures around cemented stems.…”

“…This method of imaging is regularly used at the authors' institution to confirm or discard implant loosening whenever plain radiographs and/or computed tomography imaging are insufficient to evaluate a painful THA. It has also been used in similar cases to confirm the diagnosis of femoral stress or insufficiency fracture 11,[20][21][22][23] .…”

The impact of stem fixation method on Vancouver Type B1 periprosthetic femoral fracture management

“…Periprosthetic femoral fractures (PFF) occur following total hip arthroplasty (THA) in various fracture configurations at different locations. Treatment of these can be challenging and complex and is determined by multiple factors such as bone quality, fracture topography, and stem type [1][2][3][4][5]. The Vancouver classification system is the most widely used classification system for PFF [6,7], with Type B fractures accounting for the greatest number of cases (ca.…”