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Diagnosis and Management of Intraoperative Fractures in Primary Review Article Diagnosis and Management of Intraoperative Fractures in Primary Total Hip Arthroplasty 01/21/2021 on k38zdtHxkv6vYCpY6eTuHAvjaBKfkiBvTDlT9UnCurpiFF0LpmGCRtZciWbnx/5o97dLVS/w6H4UBNoIdbWSMFPfrDRrgELMxjRi3nLPvlA5oKaJ+Q9/ELdcC+W3OaGdzSaoRM9vgAY= by http://journals.lww.com/jaaos from Downloaded Downloaded Ahmed Siddiqi, DO, MBA from Bryan D. Springer, MD http://journals.lww.com/jaaos ABSTRACT Antonia F. Chen, MD, MBA Nicolas S. Piuzzi, MD Intraoperative periprosthetic fractures are challenging complications that may affect implant stability and survivorship. Periprosthetic by k38zdtHxkv6vYCpY6eTuHAvjaBKfkiBvTDlT9UnCurpiFF0LpmGCRtZciWbnx/5o97dLVS/w6H4UBNoIdbWSMFPfrDRrgELMxjRi3nLPvlA5oKaJ+Q9/ELdcC+W3OaGdzSaoRM9vgAY= acetabular fractures are uncommon and infrequently are the focus of studies. Acetabular fractures are occasionally recognized after patients report unremitting groin pain weeks postoperatively. The widespread use of cementless acetabular cups might lead to higher number of fractures than is clinically detectable. Conversely, the incidence of intraoperative periprosthetic femoral fractures are more common and From the Department of Orthopedics, Cleveland Clinic Foundation, Cleveland, OH (Siddiqi, encompass a broad spectrum, ranging from a small cortical perforation Piuzzi), the Department of Orthopedics Atrium, to displaced fractures with an unstable prosthesis. Appropriate OrthoCarolina Hip and Knee Center, Musculoskeletal Institute, Charlotte, NC recognition, including mindfulness of preoperative patient and surgical (Springer), and the Department of Orthopedics, Brigham and Women’s Hospital, Boston, MA risk factors, is critical to the successful management of acetabular and (Chen). femoral complications. This comprehensive review article focuses on Siddiqi or an immediate family member serves as an unpaid consultant to AZ Solutions, LLC; has the incidence, patient and surgical risk factors, diagnosis, stock or stock options held in ROMTech and serves as a paid consultant to Zimmer-Biomet. management, and clinical outcomes associated with intraoperative Piuzzi or an immediate family member serves acetabular and femur fractures in primary total hip arthroplasty. as a board member, owner, officer, or committee member of ISCT; serves as a board member, owner, officer, or committee member of Journal of Knee Surgery, Journal of Hip Surgery and Orthopaedic Research Society. Piuzzi or an immediate family member has received research otal hip arthroplasty (THA) is one of the most effective and successful or institutional support from RegenLab and procedures in reducing pain, restoring function, and improving a pa- Zimmer-Biomet. Springer serves as a board tient’s overall quality of life.1–3 Hence, the demand for primary THA member, owner, officer, or committee member of T Knee Society, AJRR, AAHKS, Arthroplasty Today has increased over the past 20 years and is projected to exponentially grow in and Journal of Arthroplasty; paid consultant for the upcoming decade.4–6 This is especially relevant because complications Ceramtec, Convatec, Joint purifications systems, osteoremedies; receives royalties from Stryker. after THA are expected to concomitantly increase with the increase in on 01/21/2021 Chen serves as a board member, owner, officer, procedural volume. Most complications associated with THA are uncom- or committee member of AAOS, AJRR, AAHKS, 7 Annals of Joint, CORR, European Knee mon, preventable if anticipated, and managed when recognized. Association, Healthcare Transformation ICJR, Periprosthetic fractures (PPFx) are devastating complications related with JOA, JBJI, JBJS, JOR, KSSTA, MSIS; has received royalties and paid consultant from AMA, an increase in other postoperative complications that may lead to worse Convatec, Ethicon, GLG, Graftworx, Guidepoint, clinical outcomes and increased mortality rates.7 The prevalence of intra- Heraeus, Hyalex, Irrimax, Joint Purification operative PPFx (IPPFx) has increased in recent years with the increasing System, Pfizer, PhagoMed, Recro, SLACK 8 incorportated, Sonoran, Stryker, UpToDate. utilization of cementless implants. Overall, appropriate recognition, J Am Acad Orthop Surg 2021;00:1-16 including mindfulness of preoperative patient and surgical risk factors, is DOI: 10.5435/JAAOS-D-20-00818 critical to the successful management of both acetabular and femoral in- Copyright 2021 by the American Academy of traoperative fractures. This comprehensive review article focuses on the Orthopaedic Surgeons. incidence, patient and surgical risk factors, diagnosis, management, clinical JAAOS® - - ---- Month 2021, Vol 00, No 00 ---- © American Academy of Orthopaedic Surgeons 1 Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Intraoperative Fractures in Primary THA outcomes, and cost associated with intraoperative ace- tabular IPPFx; therefore, the true incidence and preva- tabular and femur fractures in primary THA. lence remain unknown. Because implant survivorship relies on stable bone- prosthesis interfaces, vigilant fracture identification that disrupt the femoral-implant or acetabular-prosthesis Incidence interface is critical because failure to recognize may The incidence of femoral IPPFx has been reported to be have serious implications on component function and between 0.1% and 1% for cemented and nearly 5% for survival.9 cementless primary THA.9 Other studies have reported the incidence of femur IPPFx to be as high as 27.8%.8 The discrepancy in the prevalence of this complication may be accounted for by diverse demographic data, Risk Factors multitude of femoral implant types, surgical history, and Patient Factors surgeon proficiency.10 Several patient characteristics are associated with an By contrast, periprosthetic acetabular fractures are increased IPPFx risk. Female sex and increased age are more uncommon, with reported rates as low as 0.4%.9 independent and nonmodifiable risk factors.12 Lindberg- Although cementless acetabular components in primary Larsen et al 13 found women, osteoporosis, and poor THA have become more common over the past few bone quality to have reduced cortical thickness indices decades, most fractures are unrecognized intra- leading to an increased risk of fracture. Canal bone ratio operatively. Recently, Hasegawa et al 11 reported an (CBR), or the ratio between the inner and outer diam- 8.4% prevalence of occult acetabular fracture con- eters of the proximal femur 10 cm below the less tro- firmed on postoperative computed tomography (CT) chanter, is a validated method to assess bone quality on imaging; however, these fractures were unrecognized plain radiographs with CBR $0.49 in the proximal intraoperatively or through postoperative radiographs. femur as a threshold for osteoporosis (Figure 1).14 Currently, limited population-based data exist on ace- Zhang et al 10 found that patients with CBR $0.49, Figure 1 Radiographs demonstrating the (A) canal-calcar ratio (CCR) = E/C, canal flare index (CFI) = A/E, morphological cortical index (MCI) = B/D, canal bone ratio (CBR) = E/F. (B) Anteroposterior (AP) radiograph of femur with a relatively wide canal and thin cortices suggestive of osteoporosis. CBR = 0.68 with a T score = 25.34. (C) Anteroposterior (AP) radiograph of femur with a relatively narrow canal and thick cortices. CBR = 0.34 with a T score = 22.02. (Adapted from Yeung Y, Chiu KY, Yau WP, Tang WM, Cheung WY, Ng TP. Assessment of the proximal femoral morphology using plain radiograph-can it predict the bone quality? J Arthroplasty. 2006; 21(4):508-13.) JAAOS® - - 2 ---- Month 2021, Vol 00, No 00 ---- © American Academy of Orthopaedic Surgeons Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Ahmed Siddiqi, DO, MBA, et al Review Article Figure 2 Radiographs demonstrating the Dorr classification serving as a descriptor of femoral morphology and bone quality. Type A femurs have a narrow canal with thick cortical walls (champagne flute canal). Type B femurs have moderate cortical walls. Type C femurs have a wide canal with thin cortical walls (stove-pipe canal). (Adapted from Ponzio DY, Shahi A, Park AG, Purtill JJ. Intraoperative Proximal Femoral Fracture in Primary Cementless Total Hip Arthroplasty. J Arthroplasty. 2015; 30(8):1418-22.) decreased bone mineral density, and women to be of intraoperative femur fractures during its learning associated with both intraoperative and postoperative curve.17,18 Masonis et al 17 reported three intraoperative PPFx. Dorr et al 15 classified the proximal femur mor- calcar fractures in the first 62 of 300 (4.8%) DAA THA. phology according to the CBR (Figure 2). Dorr-C Similarly, Jewitt et al 19 found that most IPPFx occur in femurs represent a lower CBR and have a 2-fold to 5- the first 200 DAA procedures (20/200 cases, 10%). The fold higher risk of intraoperative and undiagnosed learning curve is related to intrinsic femoral exposure postoperative PPFx.13 difficulty and orientation while broaching.20 In a retrospective review of 793,823 primary THA The impact of minimally invasive techniques with patients, Lamb et al 16 found a bimodal age distribution other anterior-based approaches, including the modified of older than 50 years and younger than 80 years to anterolateral (AL) and direct lateral (DL) approaches, have increased IPPFx risk along with patients with has also been reported as risk factors for IPPFx. Asayama American Society of Anesthesiologists
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