Surgical management in treating periprosthetic femoral fractures after hip arthroplasty

Abstract

Objective To observe the clinical outcomes of the surgical management of periprosthetic femoral fractures following hip arthroplasty. Methods Twelve consecutive patients (6 male and 6 female) with the average age of 66.4±15.0 years old (35 to 86 years old) undergoing surgical operation for periprosthetic femoral fractures between September 2009 and May 2016 were followed up at our center. Nine cases were fractured secondary to the primary hip arthroplasty while the others were patients with earlier revision surgery. The previous fixations of femoral components of 10 cases were cementless while the other two were cemented fixation. The enrolled patients were determined as Vancouver type B1 (n=2), type B2 (n=7), type B3 (n=1) and type C (n=2) respectively. The occurrences of the fractures were observed at 3 weeks to 17 years post-operation (average 9.0±7.0 years). The patients were treated individually according to different Vancouver types. Type B1 patients received simple cerclage fixation, as well as revisions with long-stem femoral implants and cerclage band were chosen for type B2 patients. In addition to the treatment for type B2 patients, allogenic cortical bone graft was also required for type B3 patients. Open reduction with locking plate internal fixations were options for patients with Vancouver type C fractures. The following-up included the X-ray images of the hips, Harris hip score and the visual analogue scale (VAS) for the pain of fracture site. The unions of the fractures were determined by both X-ray images and pain intensity of the fracture sites. Results The mean follow-up period was 41.6±26.0 months (range, 12-92 months), without patient lost to follow up. VAS scores were 0, implying the clinical union of the fractures. One patients received multiple debridement post-operatively due to the periprosthetic infection. The VAS score of this patient was 6 at the follow up and the X-ray image indicated the nonunion of the fracture. The fracture union rate was 91.7% (11/12). The Harris hip score was 23-92 (mean score, 74.8±18.8), excellent for 2 cases, good for 6 cases, fair for 3 cases and poor for 1 case. The excellent and good rate was 66.7% (8/12). Post-operative complications were observed in 4 patients (33.3%, 4/12). One drainage tube was misplaced and sutured subcutaneously required a further exploration surgery. One periprosthetic infection occurring post-operatively induced the nonunion of the fracture. Aseptic loosing of femoral stem was observed in 2 cases and subsequent revision surgeries were conducted. Conclusion High incidence of complications is observed after the surgical treatment of periprosthetic femoral fractures following hip arthroplasty. Individually customized management regarding to the Vancouver type of periprosthetic femoral fractures leads to the clinical fracture union in 91.7% of the patients in this case series. The excellent and good rate of the hip function in the early and mid-term stage after operation is 66.7%. Key words: Femur; Periprosthetic fractures; Arthroplasty, replacement, hip; Fracture fixation, internal