gms | German Medical Science

Objectives: Total hip arthroplasty (THA) offers a highly successful treatment option for patients with end stage hip osteoarthritis. The occurrence of an intraoperative fracture (IFF) at the proximal femur during primary THA has been frequently documented in the literature with an incidence of 0.1% to 2.5% for cemented stems and 3.7% to as high as 27.8% for uncemented stems.

The total number of IFF's is expected to grow as the demand for primary THA is predicted to increase.

Potential risk factors for IFF's in primary THA include older age, female sex, uncemented femoral components, previous hip surgery, BMI over 40 and a low etaphyseal-Diaphyseal index score.The immediate identification and proper management of an IFF is paramount to achieve end-operative stem stability and good functional results. Clinical studies with representative patient cohorts that have investigated the mid- to long-term clinical outcomes in patients with IFF in comparison with outcomes of uncomplicated THA are lacking. In particular, data on the postoperative functional outcome and satisfaction with the procedure in patients that have sustained an IFF is very limited.

The aim of the present study was to retrospectively evaluate the clinical, radiological and patient-reported outcome in a series of patients with an IFF during primary THA in comparison to patients with uncomplicated primary THA..

Methods: Fifty-two patients who sustained 53 intraoperative femur fractures during primary total hip arthroplasty at our institute between 2003 and 2015 were retrospectively reviewed. Fractures included both femur stem fractures (n=35) and Trochanter Major fractures (n=18). A control group was matched according to gender, Age, body mass index and indication for the primary total hip arthroplasty. Both groups were followed-up for a minimum duration of 2 years. The following parameters were assessed and compared: stem revision, Harris hip score improvement, pain improvement, WOMAC, Tegner Score, UCLA, SF-36, forgotten joint score and patient satisfaction.

Results and conclusion: The fracture group and the control group were followed- up for an average duration of 5.6 years (range 2-11.8) and 6 years (range: 4.1-8.3) respectively. There were 2 stem revisions in the fracture group and 1 revision in the control group. Stem survival was 96.2% and 98.1% respectively (p= 0.447). The mean Harris hip score improvement was 36.5 and 45.2 respectively. Significant differences between Harris hip score improvement (p= 0.021) and patient satisfaction (p= 0.032) were observed between the two groups. All other acquired parameters did not show significant differences.

Intraoperative fractures of the proximal femur are a relevant complication that does not lead to higher revision rates but might worsen the functional outcome and negatively impact patient satisfaction in mid- term follow-up even if treated appropriately. Care must be taken in patients with modifiable risk factors in order to decrease the incidence of this complication.