CHAPTER 2

Periprosthetic fractures;
an overview of the literature
RG Zuurmond, P Pilot, AD Verburg, SK Bulstra
Chapter 2

18
 Literature overview of periprosthetic fractures and treatment

Introduction

Total hip arthroplasty (THA) is among the most successful large operative
procedures. The prevalence is rapidly increasing due to its success. Firstly,
the improved survival rates have led to the fact that the procedure is
performed in younger patients more frequently. Secondly, the procedure is
offered to an increasing number of patients, who were previously rejected
because of old age and co-morbidity.
However, with the increasing numbers of prostheses, a higher incidence
of complications is observed. Although the number of serious complications
is low, a serious complication is a periprosthetic fracture (PPF). Today,
periprosthetic fractures are a standard problem that medium to high volume
reconstructive orthopaedic clinics have to deal with regularly.1 PPF can vary
from fractures without dislocation, with minimal or no effect on the
outcome, to being catastrophic and possibly creating a non-reconstructable
problem with an immense effect on the patient’s function.2
Often these fractures occur in older, compromised patients, raising
mortality rates.3 Both the increasing number of patients treated with THA, as
well as people getting older, create a large population “at risk”. In the
literature this increasing incidence of PPF has been reported by a number of
study groups.4,5

Incidence

The incidence and magnitude of the problem of periprosthetic fractures is

not very clear. Wide ranges of data have been reported the passed years in a
number of publications. (Table 1) The amount of periprosthetic fractures is
expected to increase next years. An increasing number of total hip
arthroplasties are performed each year and people live longer in developed
countries due to a higher living standard. Some authors show an increase of
the incidence of PPF during consecutive years. The most reliable data come
from both the Scandinavian register and the Mayo clinic register.6-8 The
National Hip Register is a well organised database in Sweden. Finland with
a comparable comprehensive registration system enabled Sarvanlinna et al.5

Table 1: Reported incidence in literature †=reported cumulative incidence

Author Year of report Sample size Incidence

Fredin9 1987 1,961 0.56%
Lewallen10 1998 17,579 0.6%
Berry6 1999 20,859 0.3%
Lindahl8 2006 242,393 0.4%†

19
Chapter 2

to show an increase in incidence during several consecutive years. Other

reports rely on clinical registrations related to numbers of implant surgical
procedures in one or more hospitals. Those data are regularly retrieved from
internal hospital registration.

While some authors describe post-operative fractures, others document

intra-operative fractures. Post-operative fractures are often caused by (minor)
trauma and intra-operative fractures are regularly reported in uncemented
stem placement or revision procedures. Intra-operative fractures are outside
the scope of this thesis and therefore only hardly mentioned.

Risk Factors
(Late) postoperative fractures
Several authors report risk factors based on their analysed series as well as
literature. Trauma is a risk factor, as minor trauma accounted for 75% of the
periprosthetic fractures (fall at height of sitting or standing). Fall at home was
a common mechanism causing periprosthetic fractures (66%).11Finally, 8%
of the fractures occurs spontaneously. Remarkable is that high energy trauma
is rarely the cause of a PPF.
Age has been often mentioned as a risk factor. However due to alterations
in bone stock, muscle strength and balance this risk is likely to be
multifactorial.12 The age at initial arthroplasty is intensively evaluated by
several authors.12-14 Age less than seventy years old at primary surgery has
been documented as a risk factor. Higher activity may play a role in these
patients or more extensive remodeling of the femur.13
Most reports did not establish gender as a risk factor. However, gender is
probably a multi-factorial risk as well since it is closely associated with
osteoporosis. Despite the few reports critically evaluating osteoporosis as a
risk factor it is commonly accepted and reported. The contribution of low
energy falls to the development of PPF and the co-existence of vertebral and
previous metaphyseal fractures in the PPF patient group support the
hypothesis. Several primary indications for hip arthroplasty are reported as
risk factors. Rheumatoid arthritis and hip fracture prior to the primary
implant were derived as risk factors from Scandinavian registries. The most
common cause of PPF is osteolysis due to particle disease and a well
established risk factor according to the literature.13 In combination with
loosening of the implant an unstable situation exists leading to increased
fracture risk. Jensen and Fredin found evidence of loosening prior to fracture
in 50% of their cases.9,15 Patients with revision implants often are more likely
to suffer from a periprosthetic fracture than do patients with a primary total
hip arthroplasty. The interval from the index surgery to fracture is shorter in
patients with revision implants. Lindahl et al. showed a mean implant
survival of 7.4 years in primary arthroplasties and 3.9 years after one
revision.8 This is in concordance with a series of our own, showing a mean

20
 Literature overview of periprosthetic fractures and treatment

of 7.8 years and 3.9 years of implant survival, respectively. (Chapter 5 of this
thesis) Stem design is much debated focused on wedged versus anatomical
design in uncemented THA. A tapered stem is expected to increase stress in
the proximal femur by some authors.16 Furthermore alterations to the femoral
integrity are known risk factors. Screw holes and cortical perforations or
previous osteotomies can have significant effect on the mechanical
properties of the bone and may lead to a fracture. However, the reports
clarifying the influence of these factors on PPF are lacking.

Classification

In the treatment of periprosthetic fractures both the patient and the type of
fracture must be taken into account, often leading to individualised treatment
methods. Several authors propose uniform treatment strategies while others
consider the whole patient in the decision making. The first step leading to
treatment decisions is to categorise conditions in a classification. For PPF
several classifications have been described.2,17-26 The earliest report is by
Parrish and Jones in 1964 describing the anatomical location of the fracture
(Table 2).27
27
Table 2. Classification of periprosthetic fractures by Parrish et al.

Group Site of fracture

Group 1 Fractures in trochanteric area
Group 2 Fractures in the proximal part of the shaft
Group 3 Fractures in the mid-shaft
Group 4 Fractures in the distal part of the shaft of the femur

After their report numerous classifications were published all based on

location of the fracture. Many of these classifications are descriptive and only
provide information on the site of the fracture, whereas they provide no
added value to the type of preferred treatment.17,20 In 1995 Duncan and
Masri incorporated quality of bone stock as well as loosening of the implant
in the Vancouver classification.19,20 (Table 3) This enabled others to work out
treatment strategies based on fracture classifications.2
More recently Ninan et al.28 introduced the more simplified Coventry
classification, while taking loosening of the implant into account. They
divide the fractures in two groups. Those with “unhappy hips” with signs of
loosening and “happy hips” with well fixed implants. The first group should
undergo revision arthroplasty, the latter might benefit from internal fixation.
Currently the most widely used classification is the Vancouver classification.

21
Chapter 2

Table 3. Vancouver classification 19

Type Site and characteristics of fracture

Type AG Fractures of greater trochanter
Type AL Fractures of lesser trochanter
Type B1 Fracture around the stem or extending just below it in which the femoral component is solidly
fixed
Type B2 Fracture around the stem or extending just below it in which the femoral component is loose
Type B3 Fracture around the stem or extending just below it in which the femoral component is loose and
there is severe bone stock loss
Type C Fractures well below the tip of the stem

Fixation methods

In accordance to the development of materials for internal fixation in normal

femora, the evolution of fixation devices has a long history. The first report
1964 by Parrish et al.27 made use of intramedullary Rush rods bypassing the
fracture. Additionally wire loops and screws were used. After this report
many different fixation methods were described.

Straps
The Parham’s straps were developed in 1913 for fracture fixation and found
their use in PPF treatment as well.17 A steel ring was tightened with a bolt
around the fracture fragments. Major drawback was the damage to the blood
supply of the femur. This led to abandoning of this concept. Partridge nylon
straps were developed in the seventies for circular fixation of the femur, having
the same negative effects on bone. Moreover the biomechanical effects limited
the use of these cables. Only few reports document results of the Partridge
system.29-31 De Ridder and colleagues concluded in a single prospective large
series that the indication for the use of this simple osteosynthesis method is
swift convalescence by splinting the periprosthetic femoral fractures.32
Supplemental use of Partridge straps is documented in a number of case
reports.33,34 More recent publications indicate that cerclage techniques lack
sufficient stability when applied without additional types of osteosynthesis.35

Cable –Plate
The capacity of cables to provide circular grip on fracture fragments lead to
the combined use of plates and cables. The Ogden plate is an example of this
development. It consists of Parham straps and stainless steel wires and
screws. Good clinical results were obtained in over 80%.36 However, finite
element analysis showed high stress areas around the end of the plate and
the need for additional wiring.37 Rotational analysis was not performed.
Therefore no strict conclusive rules could be given concerning superiority of
the implant and the post-operative management.
Dall-Miles plate cable construction offers a combination of plating, cable

22
 Literature overview of periprosthetic fractures and treatment

grip and screw fixation in multiple directions. This provides evasion of the
stem while inserting the screws. Reports with good results are published,
however in most reports implants were used (e.g. long stems, allograft struts).
The use of Dall-Miles as solitary implant delivers a failure rate of 43%.38 This
is explained by the unfavourable rotational stability. Fixation with cables
alone should therefore be avoided

Plating
Plate osteosynthesis has evolved as well. The first reports concerned
compression plating.39 Violation of the cement mantle and direction of the
screws, as well as stress rising, were concerns for the authors. Tsiridis et al.
advised to use a combination of DCP-plates and allograft struts for stable
Vancouver B1 fractures.40 In unstable implants a long stem revision was
advised in combination with a plate. Ricci et al. published a series of 37
patients with a Vancouver B1 fracture treated with plating alone, while
preserving soft tissue sleeves around the femur.41,42 An indirect reduction
was performed under fluoroscopy and fixated with uni- or bi-cortical screws.
All fractures united at 3 months with minimal complications. This
emphasises the importance of preservation of the biological environment.
Locking plates are a relatively new treatment modality. The advantages of
these implants outweigh the difficulties of indirect fracture reduction and
fracture bridging capacities of the plates. Berlusconi et al. concluded after
evaluation of their series that LCP is the gold-standard in the treatment of
Vancouver B1 fractures. Only a small series of 12 patients has been
documented in literature having a comparable failure rate to conventional
plating (16%). Median time to union was 4.8 months (4-7 months).43 Buttaro
et al.44 concluded that locking plates offer no advantages as the complication
rate is similar to the conventional plating technique. Future patients might
benefit from carbon fibre plates, described by Baker et al.45 The mechanical
properties of these plates could be beneficial. More research should be
performed as in their series periprosthetic fractures far distal to the stem were
evaluated.
A separate form of treatment with a plate is the Mennen plate, introduced
in 1979. The device consists of a clamping plate grabbing the longitudinal
femur. Early reports showed good-excellent results. However, the following
publications demonstrated inferior results. The a-traumatic theory of the
application of the plate was disputed regarding the number of non-unions
and failures. A large retrospective study from The Netherlands by Noorda and
Wuisman recorded healing rates of 72% with extensive non-weight bearing
periods and plate failure in 23%.46 They concluded against the Mennen
concept, specifically for unstable fractures.

Intramedullary fixation
Intramedullary implants have been used since the first report of periprosthetic
fractures in 1964.27 Bypassing the fracture with intramedullary rods provided
stability. Other early publications describe Ender nails and lengthened

23
Chapter 2

implants.47,48 The latter technique demands initial removal of the stem. The
intramedullary concept was limited by medullar cavities filled with cement.
Cement removal can be done by various techniques. More recently Zuurmond
et al.49 reported the use of retrograde Bridging nailing in compromised
geriatric patients, eliminating stress zones and providing stability. The clear
advantage is preservation of surrounding tissue of the femur, thus preserving
bone biology and direct post operative weight-bearing. The use of
supracondylar retrograde nails leaves a stress riser between the implants.
Coupling of the implants with a Bridging nail system eliminates this problem.

Revision stem
Many authors favor the use of a long stem revision arthroplasty in cases with
loosening of the stem. Long stems bypass the fracture and provide immediate
stability combined enabling direct postoperative mobilisation. The stem
should bypass the fracture with at least 2 times the cortical diameter.50 In
Vancouver B2 type fractures a long stem is the treatment of choice. Springer
et al.51 preferred the use of fully coated implants. Treatment of Vancouver B3
fractures is most challenging. In cases with severe additional cortical bone
loss, allograft struts are preferably used.51-53 Especially in younger patients
the emphasis is on restoration of bone stock. Proximal femoral replacement
is a salvage option, although the reported complication rates are high.54
Long term risks of revision arthroplasty are stem breakage, loosening and
instability due to poor muscle forces and capsular insufficiencies.

Biomechanics
Mechanical comparison of all these concepts generally showed superiority
when a combination of techniques was used. Cerclages tested alone are
mechanically inferior to a combination of a plate and cable. Schmotzer et
al.55 showed that proximal wiring in Ogden plates is inferior to screw
fixation. Long stem revisions in some type of fractures should be
accompanied by allograft struts. However, the effect of osseous integration
could not be established. The effect of more than one fixation device (2
plating technique or plate and allograft) demands more soft tissue stripping
and therefore biological impairment. The locking compression plate (LCP)
concept shows less favourable mechanical aspects, but the authors
emphasise the biological advantages.56

Treatment strategies

Optimal treatment for periprosthetic fractures remains a subject of discussion

in the literature. The first treatment strategies were developed by Parrish et
al.27 based on their own series. In 1981 Bethea et al.17 advised conservative
treatment in spiral fractures around the stem and for distal fractures below
the stem. Johansson et al.20 published treatment proposals and mentioned
long stem revision when the fracture stretched from stem-level to distal of the

24
 Literature overview of periprosthetic fractures and treatment

stem. However fractures proximal of the tip of the stem could be treated
conservative when the stem has a stable fixation. A large analysis of PPF was
done by Mont and Maar.24 Their data were retrieved from many small
number sub-series (critical appraisal). Although they gathered a large number
of patients their outcomes were difficult to interpret. In their plan of
treatment cerclages and revision were enclosed as well as conservative
treatment for fractures distal of the stem. For supracondylar fractures no
advice was given. Currently most treatment algorithms are based on the
Vancouver classification. In 2002 Haddad et al.52 described results for the
Vancouver B1 fractures. Cortical strut grafts offered both mechanical and
biological advantages. The most challenging fractures are the Vancouver B3
fractures with poor bone stock and loose prosthesis. Parvizi et al.2 analysed
a series of type B fractures and proposed a treatment algorithm. In case of a
loose prosthesis the algorithm always ends with large hip replacement
surgery. Recently Ninan et al.28 proposed a decision scheme base on their
treated patients. They simplified the problem, introducing the term “unhappy
hip”. These patients had a hip prosthesis with established loosening prior to
fracture, worsening hip pain, fracture with minimal trauma or radiologic
signs of loosening. They are preferably treated with a form of revision
arthroplasty. Patients without loosening or without minor trauma were
supposed to have a “happy hip” and could be treated with osteosynthesis
unless the fracture pattern caused acute instability of the stem.

Morbidity and complications

Periprosthetic fracture treatment is associated with high numbers of

complications and mortality.8,13,44,57 Reasons are high age, co-morbidity, poor
bone stock and unfavorable local biological factors. The patient group is often
compared to proximal femoral fracture patients with similar high mortality.
Recently Bhattacharyya et al.58 did a sex-matched control study comparing the
periprosthetic fracture patients with hip fracture patients. Their reported
mortality was 11% (12/106). They found a mortality rate similar to treated hip
fracture patients. Furthermore they concluded that patients treated with internal
fixation in Vancouver type B fractures had a higher mortality than patients
treated with revision arthroplasty. Selection bias may have occurred as frail
geriatric patients are not selected for long stem revision arthroplasty
procedures. They advise revision in doubtful cases. Importantly they found an
increased mortality at one year in patients with a delay of more than two days
before surgery. Lindahl et al. reported higher mortality rates after surgery for
periprosthetic fractures especially for patients younger than 70 years.8,13
Underlying disease and co-morbidity were named as possible explanations for
this remarkable finding. The estimated probability of death from PPF at the age
of 70 was 2.1% for men and 1.2% for women. In a study from Edinburgh,
McLaughlan et al.57 demonstrated a mortality rate of 20%. This rate was derived
from a retrospective analysis of 45 fracture patients with 9 deceased patients

25
Chapter 2

within 14 weeks. Another five patients remained untraced. They report that 2
patients died of a cardiac event due to cement insertion during surgery. The co-
morbidity of the patients was regarded as the main cause of the other
postoperative deaths. Several studies report their results regarding an operative
policy including complications and deaths. An overview is given in Table 4. The
study of Ninan et al.28 describing a treatment strategy had a mortality of 13%
(7/53). The re-operation rate was 19% (10/53). The latter clarified by refractures
and infections. Parvizi et al.2 did not report the length of follow up. One direct
postoperative death was encountered in his series of 123 PPF patients. A total
of 22 complications were reported (18%) including seven failures of the
construction were reported (6%). There is a wide range of mortality numbers
given by the different authors. In general larger series show worse numbers.

Table 4. Reported mortality and reoperations in the literature.

Study Year Number Confirmed Reported Mortality

of patients Reoperations complications
59
Cooke 1988 37 12 (32%) n/r 0
McLaughlan57 1997 45 3 (7%) 5 (11%) 9 (20%)
60
Tsiridis 2002 16 4 (25%) 2 (13%) 1 (6%)
2
Parvizi 2004 123 7 (6%) 22 (18%) 1 (1%)
61
Klein 2005 21 4 (19%) 6 (29%) 3 (14%)
Lindahl62 2006 1045 109 (10%) n/r n/r
Kaab63 2006 13 1 (8%) 3 (23%) 0
Lindahl8 2006 321 54 (17%) 45 (14%) 42 (34%)
Buttaro44 2007 14 4 (30%) 7 (50%) 0
28
Ninan 2007 53 10 (19%) n/r 7 (13%)
58
Bhattacharyya 2007 106 n/r n/r 12 (11%)
Overview of reported reoperations and complications
n/r= not reported

Several authors have tried to evaluate risk-factors for development of

complications after periprosthetic fractures. A risk factor defined by Lindahl
was plate osteosynthesis for a Vancouver B1 fracture. 13

Discussion

When discussing the problem of periprosthetic fractures, the emphasis is

more on the difficulty of treatment than on the increasing incidence. The
incidence is expected to increase due to ageing and increasing numbers of
total hip arthroplasties performed. The number of THA performed in The
Netherlands almost doubled since 1992, resulting in approximately 25.000
procedures in 2006. The incidence of PPF is reported between 1% and
6%.4,6,9,10,19 Uncemented stems show higher numbers, especially when

26
 Literature overview of periprosthetic fractures and treatment

combined with intra-operative fractures. Operative technique and bone

quality may play an important role in the aetiology.
The access to an implant registry facilitates the study of long term
complications. Great examples are the Swedish Hip Register and the
Norwegian Register. When a separate code for periprosthetic femoral
fractures is defined, exact numbers can be reported. The inclusion of fracture
classification system for PPF is preferable for research purposes. The
Vancouver classification is most widely used and easy to apply. Other
classification methods could be more precise on some points, but are less
reliable when it comes to inter-observer variability. Classifications with the
purpose to establish a treatment protocol have been reported. Some authors
28,64
tend to advise revision in all cases of loosening to prevent adverse
effects and implant stability problems. However, no reports critically
mention the impact of a revision arthroplasty on older patients. A-
symptomatic loosening of hip stems in institutionalised patients are not
undoubtedly feasible indications for revision. When a periprosthetic fracture
occurs, the general health aspects of these patients should be addressed and
enclosed in the treatment algorithm.
During the past years several methods of fracture fixation found their use
in periprosthetic fracture treatment. The emphasis is on revision arthroplasty
in fractures with a loose stem. For stable implants numerous forms of internal
fixation are at the disposal of the treating surgeon. Cerclage systems should
be accompanied by other forms of fixation in order to diminish
complications. Plate fixation is associated with mechanical complications as
well, especially in type B1 fractures. Bone biology is an important aspect in
fracture healing. Recent developments in plate osteosynthesis, including
indirect fracture reduction and less invasive procedures, tend to respect
surrounding tissue. This may be beneficial to fracture healing, although
callous formation is generally delayed after plate osteosynthesis of the femur.
Unfortunately, early load bearing and ambulation are not frequently feasible
when these techniques are performed.
The importance of early mobilisation lies in the prevention of general
complications. To reduce the rate of complications and to optimise the
treatment for periprosthetic fractures more research is needed. This research
should focus on the holistic outcome for the patient in favour of studies of
one specific (new) implant. Regarding the low incidence, this is preferably
performed in a multi-centre trial in a prospective way. Patient based outcome
scores for quality of life and activities of daily life should certainly be
included in this registration to complete the picture.

27
Chapter 2

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29
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