The Journal of Arthroplasty xxx (2015) xxxxxx

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

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 b,
Manish R. Dastane, MD b, Daniel J. Berry, MD a
a
b

Mayo Graduate School of Medicine, Mayo Clinic, Rochester, Minnesota

Arthritis Institute, Centinela Hospital Medical Center, Inglewood, California

a r t i c l e

i n f o

Article history:
Received 27 January 2015
Accepted 20 May 2015
Available online xxxx
Keywords:
postoperative
THA
uncemented
outcomes
primary

a b s t r a c t
Thirty Vancouver type B periprosthetic fractures occurred within 90 days of total hip arthroplasty were identied
using 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 288 days (mean 28). Mechanism of injury was fall from standing height in 12, no dened trauma in 11,
stumble without fall in 5, and twisting motion in 2. Fracture treatment consisted of femoral revision in 24,
fracture xation in two, and nonoperative in four. Of the 24 treated with revision, 21 had healed fractures and
stable revision stems.
2015 Elsevier Inc. All rights 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 after
primary uncemented THA are one of the most frequent early modes of
implant failure and one of the most common complications leading to
early revision [13]. The purpose of this study was to characterize
early periprosthetic femur fractures after uncemented primary THA
with respect to fracture pattern, frequency, circumstances of occurrence, and outcome of treatment. The fractures uniquely strongly associated 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, 19,271 consecutive primary total hip arthroplasties were performed at the authors two institutions of which 7447 were performed utilizing an uncemented
proximally porous coated collarless femoral component. Over this

One or more of the authors of this paper have disclosed potential or pertinent conicts
of interest, which may include receipt of payment, either direct or indirect, institutional
support, or association with an entity in the biomedical eld which may be perceived to
have potential conict of interest with this work. For full disclosure statements refer to
http://dx.doi.org/10.1016/j.arth.2015.05.044.
Source of Funding: There was no external funding for this study.
Reprint requests: Daniel J. Berry, M.D., Mayo Clinic, 200 First Street SW, Rochester, MN
55905.

time period stems of many designs were implanted at the two institutions, and stem design was chosen at the discretion of the surgeon.
The computerized databases of the authors two institutions were
used 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 radiographs of all hips that sustained a fracture were evaluated by two of the
authors (DJB and MJT). Bone morphology was assessed on the preoperative radiographs according to the criteria of Dorr [46]. Fractures
were classied according to the Vancouver system described by Duncan
and Masri [7]. This classication system has been validated and
shown to have high intraobserver and interobserver reliability [8].
At the authors two institutions it is routine to obtain postoperative
anteroposterior and lateral radiographs immediately after the operation
on the day of surgery. All radiographs were conrmed to have no visible
fracture on immediate postoperative radiographs.
Operative reports and clinical notes were reviewed to correlate clinical factors. Patients with a fracture identied intraoperatively were excluded. Data from the early postoperative period were reviewed and
recorded, including the patients location at the time of fracture (hospital, rehabilitation facility, or at home), the patients weight bearing status, rehabilitation protocol, support used at the time of fracture (walker,
cane, or crutches), and activity at time of fracture event. Clinical data regarding outcome of the fracture and its treatment were collected at the
time of most recent followup evaluation.

http://dx.doi.org/10.1016/j.arth.2015.05.044
0883-5403/ 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Taunton MJ, et al, Early Postoperative Femur Fracture After Uncemented Collarless Primary Total Hip Arthroplasty: Characterization and Results of Tre..., J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.044

M.J. Taunton et al. / The Journal of Arthroplasty xxx (2015) xxxxxx

The xation of cemented stems after revision was assessed according to the criteria of Harris et al [9]. The xation 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 signicance was set at P b 0.05.
Results
Vancouver type B femur fractures were identied to have occurred
in the rst 90 days after THA in 30 hips (30 patients) among the 7447
hips for an incidence of 0.4%. There were 18 females and 12 males
with a mean age of 63 years (range 2584 years). The mean body
mass index was 31 (range 2146). 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
one hip. Fifteen patients had Dorr type A proximal femoral bone morphology and 15 had type B 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 (1.6% fracture rate), APR (Zimmer,
Warsaw, IN) in 3422 pts with 10 fractures (0.1% fracture rate), Omniex
(Stryker, Kalamazoo, MI) in 942 patients with 4 fractures (0.4% fracture
rate), Summit (Depuy, USA) in 1208 patients with 3 fractures(0.3% fracture rate), and Secur-Fit Hydroxyapatite (Stryker, Kalamazoo, MI) in
1213 patients with 2 fractures (0.2% fracture rate).
The mean time between the arthroplasty and fracture was 28 days
(range 288 days). The mechanism of injury consisted of a fall from
standing height in 12 patients, no dened trauma in 11 patients, a trip
or stumble in ve 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 1
was using a cane. Nineteen patients had been instructed that they
could weight bear as tolerated on the operative limb at the time of fracture, 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 lesser trochanter (Figs. 1 and 2). The average
distance below the lesser trochanter that the fracture exited the medial
cortex was 3.7 cm (range 011 cm). In two of these 28 hips, in which
this same fracture pattern was conrmed 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 type B 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 component revision and fracture stabilization in 24 hips, reoperation with
stem retention and fracture stabilization in 2, and nonoperative treatment in 4. Twelve femoral components were revised to an extensively
porous coated uncemented stem, 6 were revised to a uted-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 3219 months). The average preoperative Harris Hip score was
42 (range 1367). This improved to an average postoperative Harris
Hip score of 76 (range 32100) at latest followup.
At latest followup, the 4 femur fractures that were selected for nonoperative treatment had healed and the implants were radiographically

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.

stable. The 2 femurs that were selected for treatment with internal
xation 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 [13]. Little is known
about the fracture patterns, clinical circumstances, and results of treatment when these fractures occur in contemporary practice. The primary
purpose of this paper was to characterize the pattern and clinical
circumstances surrounding these fractures when they occur in conjunction with a commonly used class of uncemented femoral components
collarless uncemented stems. A secondary goal was to report early results of treatment.
Twenty-eight of the 30 Vancouver type B fractures in this report
were of a single stereotypical pattern characterized by a separate fragment of posterior medial cortical bone that included the lesser trochanter. We classied these fractures as Vancouver type B periprosthetic
femur fractures, rather than Vancouver A(L) fractures, which are described as avulsion fractures of the lesser trochanter. The fractures described in this report typically were associated with stem subsidence
and stem rotation to a relatively retroverted position. Because the fracture is usually associated with loss of implant xation 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

Please cite this article as: Taunton MJ, et al, Early Postoperative Femur Fracture After Uncemented Collarless Primary Total Hip Arthroplasty: Characterization and Results of Tre..., J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.044

M.J. Taunton et al. / The Journal of Arthroplasty xxx (2015) xxxxxx

Fig. 2. (A) Immediate postoperative radiograph of an 84 year old man after uncemented THA. (B) Radiograph 27 days post-operatively after the patient had increased pain at rehabilitation
facility while using a walker ambulating weight bearing as tolerated. (C) Radiograph after revision to a uted tapered modular stem.

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

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 uted tapered stem.
(D) Radiograph after component resection for infection following revision operation.

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 actual stem. As the nal stem is impacted, hoop stresses occur. The viscoelastic nature of the bone allows for creep and stress relaxation of the
bone [11]. As the press-t lessens with relaxation, the high roughness
of the porous surface, the tapered design, and perhaps 3-point xation
provide further initial stability. The mechanical properties of these tapered stems then translate to working best in proximal femoral morphology with these tapered medullary shapes, allowing for maximal
implantbone contact. For patients with weak proximal femoral bone
that does not provide reliable xation of an uncemented implant, or
that may be at high risk for fracture, cemented femoral component xation with optimal implant designs can provide a high rate of success.
Rapid mobilization of patients with early full weight bearing has become 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 smaller incisions may make it difcult for a surgeon to identify an intraoperative fracture and treat it intraoperatively.
In most cases in this report the fracture was treated with reoperation
consisting of femoral component revision and fracture stabilization
with cerclage, because in most cases the femoral component had lost
xation, subsided and/or become retroverted as a consequence of
these fractures. Two cases were successfully treated with fracture stabilization 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 postoperative 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

Please cite this article as: Taunton MJ, et al, Early Postoperative Femur Fracture After Uncemented Collarless Primary Total Hip Arthroplasty: Characterization and Results of Tre..., J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.044

M.J. Taunton et al. / The Journal of Arthroplasty xxx (2015) xxxxxx

fracture was the beginning of a cycle of further complications leading to

notable morbidity.
By making surgeons aware of clinical circumstances associated with
early periprosthetic femur fracture, the authors hope some such fractures may be avoided in the future. Careful consideration may be
given to the indications for use of these categories of femoral components 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 lesser trochanter. Thorough intraoperative
scrutiny of the femoral neck after implant placement may identify some
nondisplaced fractures and allow intraoperative treatment with
cerclage xation. 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. And nally, patient education about fracture risk may encourage caution to avoid
circumstances that could lead to stumble or fall in the early postoperative time period.

References
1. Havelin LI. The Norwegian Joint Registry. Bull Hosp Jt Dis 1999;58(3):139.
2. National Joint Registry for England and Wales 9th annual report; 2012 [http://www.hqip.
org.uk/assets/NCAPOP-Library/NCAPOP-2012-13/NJR-9th-Annual-Report-2012.pdf].
3. Australian Orthopaedic Association. National Joint Replacement Registry annual report; 2014 [http://aoanjrr.dmac.adelaide.edu.au/documents/10180/172286/Annual%
20Report%202014].
4. Dorr LD, Absatz M, Gruen TA, et al. Anatomic porous replacement hip arthroplasty:
rst 100 consecutive cases. Semin Arthroplasty 1990;1(1):77.
5. Dorr LD, Faugere MC, Mackel AM, et al. Structural and cellular assessment of bone
quality of proximal femur. Bone 1993;14(3):231.
6. Dossick PH, Dorr LD, Gruen T, Saberi MT. Techniques for pre-operative planning and
post-operative evaluation of non-cemented hip arthroplasty. Tech Orthop 1991;6:1.
7. Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293.
8. Brady OH, Garbuz DS, Masri BA, et al. The reliability and validity of the Vancouver classication of femoral fractures after hip replacement. J Arthroplasty 2000;15(1):59.
9. Harris WH, McCarthy Jr JC, O'Neill DA. Femoral component loosening using contemporary techniques of femoral cement xation. J Bone Joint Surg Am 1982;64(7):1063.
10. Engh CA, Massin P. Cementless total hip arthroplasty using the anatomic medullary
locking stem. Results using a survivorship analysis. Clin Orthop Relat Res 1989(249):141.
11. Mallory TH, Head WC, Lombardi Jr AV. Tapered design for the cementless total hip
arthroplasty femoral component. Clin Orthop Relat Res 1997;433:172.

Please cite this article as: Taunton MJ, et al, Early Postoperative Femur Fracture After Uncemented Collarless Primary Total Hip Arthroplasty: Characterization and Results of Tre..., J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.044