A study of periprosthetic fractures following hemi-arthroplasty of hip in elderly population: diagnosis and management

INTRODUCTION

In elderly hip fractures pose a major public health problem.¹ These fractures form around one-fourth of all fractures in patients aged 75 years and over.² Femoral neck fractures occur most frequently in elderly female patients following fall from standing height and may be associated with osteoporosis.³ Hip hemi-arthroplasty is one of the recommended treatment options in the elderly low mobility population as the large diameter hemi-arthroplasty head component reduces the risk of dislocation: total hip replacement is the recommended option in the more active population as it can provide a better functional outcome.^4-9

Various complications like deep soft tissue infection, deep vein thrombosis, dislocation or implant failure can occur following hemi-arthroplasty of hip. Review of the three large scale studies, which reported on implant-related complications, revealed the most common complication was peri-prosthetic femoral fracture.¹⁰ Femoral periprosthetic fractures can occur during the index hemi-arthroplasty surgery or postoperatively. The well-known Vancouver classification system, developed by Duncan and Masri et al for fractures of femur after total hip arthroplasty is considered the most reliable method for assessment of intra-/postoperative femoral fractures according to the location of the fracture and the presence of a well-fixed or loose component.¹¹ This system is commonly used worldwide, and shows good correlation between radiological and intraoperative clinical findings.^12,13 This classification system has also been altered to include intraoperative fractures and perforations.¹⁴

The aim of this retrospective study is to analyze the diagnosis of peri-prosthetic fractures and their subsequent management in elderly patients who had undergone hemi-arthroplasty of hip for fracture of femoral neck.

METHODS

A total of 26 patients from March 2018 to September 2019 who suffered from peri-prosthetic fractures during or after the uncemented hemi-arthroplasty of hip, in Government Medical College and Hospital, Aurangabad were included in the study. A retrospective analysis of the radiological and clinical diagnosis and management of peri-prosthetic fractures was performed. 17 out of 26 fractures were iatrogenic and occurred during the index surgery. 9 fractures were caused by low energy fall.

We assessed patient reports focusing on type of fracture, procedure done for management of said peri-prosthetic fracture, operative time and type of fixation. We used Vancouver classification system (Figure 1 and 2).

Type A

Involve proximal metaphysis (subdivided into AG or AL with greater trochanter and lesser trochanter involvement respectively).

Type B

Fractures occur around the stem or just below it (subdivided in B1 if the stem was stable, B2 in case of loose stem with adequate bone stock and B3 loose stem without fair bone stock).

Type C

Fractures occur below the stem tip.

Particular attention was paid on stem stability evaluation conducted in all patients with X-rays and intraoperative assessment. After the exposure the fracture site we accurately evaluated the stem stability for ultimate surgical decision.

Redrawn from Greidanus, Mitchell, and Masri et al principles of management and results of treating the fractured femur during and after total hip arthroplasty, Instr Course Lect 52:309, 2003.¹⁴

All surgeries for peri-prosthetic fractures were performed by utilization of previously placed incision scar via posterior approach with proximal and distal extensions as and when needed. All surgeries for peri-prosthetic fractures were performed by utilization of previously placed incision scar via posterior approach with proximal and distal extensions as and when needed.

The treatment given was morselized bone graft obtained from extracted femoral head with or without cerclage (utilizing K wires and tension band wiring technique for AG fractures (Figure 3) for all type A fractures as they were recognized intra-operatively. Open reduction and internal fixation (ORIF) with original implant in-situ for all B₁ (Figure 4) and all C fractures were done as the second and definitive procedure after the confirmation of diagnosis. Revision along with ORIF was required for all B₂ and B₃ cases. The length of hospitalization and time to union were analysed.

All patients were followed up till 1.5 years postoperatively. Radiological and clinical evaluations were conducted after 1, 3, 6, 12 months and 18 months after the surgery for peri-prosthetic fractures.

Statistical analysis was done on microsoft excel sheet using SPSS25 utilizing microsoft excel 10 and microsoft word 10.

RESULTS

In the study 12 men and 14 women with a mean age of 73.38±8.01 years at the time of presentation were included. Primary implant was unipolar AMP in 10 and bipolar prosthesis in 16 patients. According to Vancouver classification of peri-prosthetic fractures, 10 fractures were classified as type A, 7 as type B₁, 3 as type B₂, 4 as type B₃ and 2 type C (Table 1).

Follow up was divided on the basis of the surgery done in type A fractures, fractures of greater trochanter (AG) were managed with tension-band wiring using K wires, fractures of lesser trochanter (AL) were managed using morselized local graft obtained from extracted head. All type A fractures healed uneventfully. Type B₁ and C fractures were managed with ORIF (plate and screws); type B₂ and B₃ fractures were managed with a longer stem revision hemi-arthroplasty. The mean surgical time for operative procedure required for the treatment of peri-prosthetic fractures was 120±10 minutes. The mean hospital stay of patients was 8 days. 22 out of 26 patients went on have uneventful union and reported no complications after the surgery and 4 patients developed infected non-union, 2 patients from type B2 with 1 from B3 and type C each.

DISCUSSION

The prime goal of management of peri-prosthetic hip fracture is timely and correct diagnosis according to Vancouver classification, appropriate surgical procedure which ultimately leads to adequate bone healing and early return to pre-injury function. Advanced age, osteoporosis, co-morbidity and age-related weakness that lead to low energy trauma are cited as the most frequent cause of peri-prosthetic injuries.¹⁵

In Lindhall et al study 47% of B₂ fractures were classified initially as B1, in relation with radiological findings.¹⁶ Also Fleischman et al reported high number of failures in B₁ fracture (assumed fix stem) treated with ORIF techniques comparing with B₂ fracture underwent revision.¹⁷ Khan et al suggest accurate radiological evaluation especially in patients with pre-existing thigh pain.¹⁸ Specific localization of the fracture, such as near area of lysis below an apparently well fixed stem should lead to decide for revision surgery.^19,20 This is supported by Swedish National Hip Arthroplasty Register data that show higher percentage of re-operation after ORIF without stem revision 32% compare with revision alone 10% or revision in association with internal fixation 23%.¹⁶

Although various standard head sizes ranging from 37 to 53 were available, due to economic constraints a universal implant type (either unipolar Austin Moore-Prosthesis or bipolar prosthesis) with fixed stem morphology was the only available implant that could be used routinely in a tertiary government center like ours. This may be associated with high rate of intra-operative peri-prosthetic fractures, especially type A variants. An appropriate surgical technique and an anticipation of narrow canal should warrant more gentle and diligently done procedure in these elderly patients with a weak bone stock.

CONCLUSION

As evident in our study, majority of fractures occurred intra-operatively, a thorough evaluation of pre-operative X-rays of pelvis with both hips in both AP and lateral view should be done along with special focus on anatomical variations like excessive proximal femoral bowing. Correct diagnosis based on radiological and intraoperative findings followed by appropriate treatment are of paramount importance in the management of peri-prosthetic fractures. Although unipolar implants were associated with lesser frequency and severity of peri-prosthetic fractures, a larger study group is required for establishing that unipolar implants are better than bipolar implants for hemi-arthroplasty of hip for neck femur fractures.

ACKNOWLEDGEMENTS

We want to extend our token of appreciation towards our Professor and Head of the Department Dr. Chandrakant R. Thorat sir who has relentlessly worked for the betterment of our department and thank him for his everlasting support in all our endeavours.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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