- Email: [email protected]
Periprosthetic fractures in the resurfaced hip—A case report and review of the literature
Injury, Int. J. Care Injured 44 (2013) 263–265
Contents lists available at SciVerse ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case report
Periprosthetic fractures in the resurfaced hip—A case report and review of the literature Stephen A. Brennan *, Brian M. Devitt, Cathleen J. O’Neill, Paul Nicholson Adelaide and Meath Hospital, Dublin, Ireland
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 4 September 2012
Traumatic periprosthetic fractures adjacent a hip resurfacing prosthesis are rare. When proximal fractures are encountered the obvious surgical solution is to revise to a large head stemmed femoral component. A previously well functioning implant may however be retained as various non-operative and operative treatment options exist. This paper reports the case history of a traumatic periprosthetic fracture successfully treated with cannulated screw fixation and reviews the current literature. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Periprosthetic fracture Hip resurfacing
Introduction The femoral neck fracture rate in the first year following hip resurfacing has been reported as 1.31%.1 There are both patient and surgeon controlled factors which contribute to the risk of fracture. Female gender, a high body mass index and osteoporosis have all been associated with an increased risk.2 Surgical factors such as femoral neck notching and a malpositioned femoral component may also contribute to this mode of failure.3,4 There is a naturally occurring rate of femoral neck fracture in a population regardless of whether or not they have had resurfacing surgery. As this young active population ages, we are likely to encounter a rise in periprosthetic fractures adjacent resurfacing implants. When secondary to avascular necrosis the usual treatment is conversion to a stemmed femoral component. In the setting of trauma however both non-operative and operative treatment options exist. This paper reports a periprosthetic fracture in a resurfaced hip successfully treated with cannulated screw fixation and reviews the current literature. Case report A healthy 69-year old male with end stage osteoarthritis of his right hip underwent Birmingham (Smith & Nephew, Memphis, Tenn) Hip Resurfacing through an anterolateral approach. His postoperative course was uneventful and at six-month follow up he was pain free and had returned to full activity. One year following his index procedure he fell from a standing height sustaining a basal cervical periprosthetic fracture (Figs. 1–4).
* Corresponding author. Tel.: +353 01 4142000; fax: +353 091 526588. E-mail address: [email protected] (S.A. Brennan). 0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.09.004
The fracture was reduced closed under traction. Two 6.5 mm Richards cannulated screws (Smith & Nephew, Memphis, Tenn) were placed into the superior neck under image guidance. The patients surgery took place less than twelve hours after injury. The patient was discharged home on the second post-operative day on crutches touch toe weight bearing for six weeks. At two years follow up the patient was asymptomatic and had returned to distance running. His Harris Hip score was 98. Radiologically the fracture was united with remodeling evident. Discussion When a traumatic periprosthetic fracture is encountered the surgeon must decide whether to retain a previously well functioning prosthesis or convert to a stemmed total hip replacement. There a number of case reports supporting a conservative treatment strategy for un-displaced neck of femur fractures.5–7 Non operative treatment involves a prolonged period of immobility. This has the associated risks of deep venous thrombosis and lower respiratory tract infection. In addition, this method of treatment may lead to loss of muscle mass and prolong pain during healing. When considering surgical fixation the main obstacle encountered is adequate proximal fragment purchase, whilst avoiding the femoral stem and not disrupting the cement mantle. The target area between the stem and the inner surface of the femoral component in a 50 mm Birmingham implant is 17.2 mm. This is large enough to easily accommodate the threads of a 6.5 mm Richards screw. Placement of a 12.7 mm Compression Hip Screw (Smith and Nephew, Memphis, Tenn) and side plate construct would be technically challenging and risk disruption of the cement mantle. Other technical considerations include an acceptable reduction so as to avoid edge loading and adverse wear.
S.A. Brennan et al. / Injury, Int. J. Care Injured 44 (2013) 263–265
264
Fig. 3. Post-operative antero-posterior radiograph. Fig. 1. Antero-posterior view radiograph showing periprosthetic fracture.
Fig. 2. Lateral radiograph showing periprosthetic fracture.
Cannulated screws have been used successfully to treat mid-cervical, basi-cervical and inter-trochanteric neck of femur fractures (Table 1).8–10 If the fracture is intra-capsular and grossly displaced however this method should be avoided because avascular necrosis of the head remnant may result in early failure.11 Inter-trochanteric fractures have also been managed successfully with a blade plate, reversed distal femoral locking plates and proximal femoral locking plates.12–15 These methods of fixation require extensive dissection with increased resultant blood loss when compared to cannulated screws. In addition to this the
Fig. 4. Post-operative lateral radiograph.
insertion of a blade plate adjacent a resurfacing is technically demanding and there is potentially reduced hold on the proximal fracture fragment. Sub-trochanteric fractures have been treated using a reconstruction nail, contoured AO DCP and more recently trochanteric entry point cephallo-medullary nails.16–18 The DCP is an attractive option if an intramedullary nail is likely to cause further comminution, achieve inadequate fixation in the femoral neck or if the fixed angulation of the locking screws within the nail is
Table 1 Summary of publications. Author
Year
Journal
No. of cases
Fracture location
Treatment
Cumming Aning16 Cossey6 Morgan7 Weinrauch12 Kutty8 Merredy9 Orpen13
2003 2005 2005 2008 2008 2009 2009 2009
JBJS (Br) Injury J Arthroplasty Injury extra JBJS (Am) JBJS (Br) Injury extra Injury extra
1 1 7 2 1 1 1 2
Conservative Reconstruction nail Conservative Conservative Blade plate Cannulated screws Cannulated screws Distal femoral locking plate
Zustin11 Whittingham-Jones17 Baxter14 Lein10 Silk15 Peskun18
2009 2010 2010 2010 2011 2012
Acta Orthopaedica J Arthroplasty Hip International Unfallchirurg Injury extra J Arthroplasty
1 1 1 1 1 2
Subcapital Sub-trochanteric Undisplaced neck of femur Inter-trochanteric Inter-trochanteric Mid cervical Basi-cervical (a)Inter-trochanteric (b)Reverse oblique per-trochanteric Mid-cervical Sub-trochanteric Inter-trochanteric Inter-trochanteric Intra-trochanteric Inter-trochanteric Sub-trochanteric
5
Cannulated screws DCP plate Distal femoral locking plate AO Lag screws Proximal femoral locking plate Cephallo-medullary nail
S.A. Brennan et al. / Injury, Int. J. Care Injured 44 (2013) 263–265
precluded by the stem of the resurfacing arthroplasty. An intramedullary nail is however biomechanically favourable to a plate and is a load sharing construct. In addition to this it can be inserted in a minimally invasive manner with little blood loss. Conclusion Revising the hip to a long stemmed femoral component negates the benefits of conservation of femoral bone stock in the young patient and involves removing an otherwise well aligned and fixed implant. Traumatic femoral neck fractures involving hip resurfacing prostheses may be treated surgically without revision with a good functional outcome. Conflict of interest statement The authors declare that they have no conflict of interest. References 1. Kohan L, Field CJ, Kerr DR. Early complications of hip resurfacing. Journal of Arthroplasty 2012. [Epub ahead of print, Apr 13]. 2. Marker DR, Seyler TM, Jinnah RH, Delanois RE, Ulrich SD, Mont MA. Femoral neck fractures after metal-on-metal total hip resurfacing: a prospective cohort study. Journal of Arthroplasty 2007;22(7 Suppl. 3):66. 3. Anglin C, Masri BA, Tonetti J, Hodgson AJ, Greidanus NV. Hip resurfacing femoral neck fracture influenced by valgus placement. Clinical Orthopaedics and Related Research 2007;465:71. 4. Shimmin AJ, Back D. Femoral neck fractures following Birmingham hip resurfacing: a national review of 50 cases. Journal of Bone and Joint Surgery British Volume 2005;87:463. 5. Cumming D, Fordyce MJ. Non-operative management of a peri-prosthetic subcapital fracture after metal-on-metal Birmingham hip resurfacing. Journal of Bone and Joint Surgery British Volume 2003;85(September (7)):1055–6.
265
6. Cossey AJ, Back DL, Shimmin A, Young D, Spriggins AJ. The nonoperative management of periprosthetic fractures associated with the Birmingham hip resurfacing procedure. Journal of Arthroplasty 2005;20(April (3)): 358–61. 7. Morgan D, Myers G, O’Dwyer K, Thomas AM. Intertrochanteric fracture below Birmingham Hip Resurfacing: successful non-operative management in two cases. Injury Extra 2008;39–9:313–5. 8. Kutty S, Pettit P, Powell JN. Intracapsular fracture of the proximal femur fracture after hip resurfacing treated by cannulated screws. Journal of Bone and Joint Surgery British Volume 2009;91(August (8)):1100–2. 9. Mereddy P, Malik H, Geary N. Peri-prosthetic fracture of femur following metalon-metal Birmingham hip resurfacing treated by internal fixation. Injury Extra 2008. 10. Lein T, Schlee J, Kothe M, Moritz F, Wubtaye DT. Periprosthetic intertrochanteric fracture of the femur following articular resurfacing of the hip joint: treatment with lag screw osteosynthesis. Unfallchirurg 2010;113(November (11)): 944–50. 11. Zustin J, Winter E. Failed internal fixation due to osteonecrosis following traumatic periprosthetic fracture after hip resurfacing arthroplasty. Acta Orthopaedica 2009;80(December (6)):666–9. 12. Weinrauch P, Krikler S. Proximal femoral fracture after hip resurfacing managed with blade-plate fixation. A case report. Journal of Bone and Joint Surgery 2008;90(June (6)):1345–7. 13. Orpen NM, Pearce O, Deakin M, Keys RI. Internal fixation of trochanteric fractures of the hip after surface replacement. Injury Extra 2009;40: 32–5. 14. Baxter JA, Krkovic M, Prakash U. Intertrochanteric femoral fracture after hip resurfacing managed with a reverse distal femoral locking plate: a case report. Hip International 2010;20(October–December (4)):562–4. 15. Silk G, Sangster M, Sandhu H. Internal fixation of trochanteric fracture following hip resurfacing. Injury Extra 2011;42:183–5. 16. Aning J, Aung H, Mackinnon J. Fixation of a complex comminuted proximal femoral fracture in the presence of a Birmingham hip resurfacing prosthesis. Injury 2005;36(September (9)):1127–9. 17. Whittingham-Jones P, Charnley G, Francis J, Annapureddy S. Internal fixation after subtrochanteric femoral fracture after hip resurfacing arthroplasty. Journal of Arthroplasty 2010;25(February (2)):334. 18. Peskun CJ, Townley JB, Schemitsch EH, Waddell JP, Whelan DB. Treatment of periprosthetic fractures around hip resurfacings with cephalomedullary nails. Journal of Arthroplasty 2012;27(March (3)):494.
Contents lists available at SciVerse ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case report
Periprosthetic fractures in the resurfaced hip—A case report and review of the literature Stephen A. Brennan *, Brian M. Devitt, Cathleen J. O’Neill, Paul Nicholson Adelaide and Meath Hospital, Dublin, Ireland
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 4 September 2012
Traumatic periprosthetic fractures adjacent a hip resurfacing prosthesis are rare. When proximal fractures are encountered the obvious surgical solution is to revise to a large head stemmed femoral component. A previously well functioning implant may however be retained as various non-operative and operative treatment options exist. This paper reports the case history of a traumatic periprosthetic fracture successfully treated with cannulated screw fixation and reviews the current literature. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Periprosthetic fracture Hip resurfacing
Introduction The femoral neck fracture rate in the first year following hip resurfacing has been reported as 1.31%.1 There are both patient and surgeon controlled factors which contribute to the risk of fracture. Female gender, a high body mass index and osteoporosis have all been associated with an increased risk.2 Surgical factors such as femoral neck notching and a malpositioned femoral component may also contribute to this mode of failure.3,4 There is a naturally occurring rate of femoral neck fracture in a population regardless of whether or not they have had resurfacing surgery. As this young active population ages, we are likely to encounter a rise in periprosthetic fractures adjacent resurfacing implants. When secondary to avascular necrosis the usual treatment is conversion to a stemmed femoral component. In the setting of trauma however both non-operative and operative treatment options exist. This paper reports a periprosthetic fracture in a resurfaced hip successfully treated with cannulated screw fixation and reviews the current literature. Case report A healthy 69-year old male with end stage osteoarthritis of his right hip underwent Birmingham (Smith & Nephew, Memphis, Tenn) Hip Resurfacing through an anterolateral approach. His postoperative course was uneventful and at six-month follow up he was pain free and had returned to full activity. One year following his index procedure he fell from a standing height sustaining a basal cervical periprosthetic fracture (Figs. 1–4).
* Corresponding author. Tel.: +353 01 4142000; fax: +353 091 526588. E-mail address: [email protected] (S.A. Brennan). 0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.09.004
The fracture was reduced closed under traction. Two 6.5 mm Richards cannulated screws (Smith & Nephew, Memphis, Tenn) were placed into the superior neck under image guidance. The patients surgery took place less than twelve hours after injury. The patient was discharged home on the second post-operative day on crutches touch toe weight bearing for six weeks. At two years follow up the patient was asymptomatic and had returned to distance running. His Harris Hip score was 98. Radiologically the fracture was united with remodeling evident. Discussion When a traumatic periprosthetic fracture is encountered the surgeon must decide whether to retain a previously well functioning prosthesis or convert to a stemmed total hip replacement. There a number of case reports supporting a conservative treatment strategy for un-displaced neck of femur fractures.5–7 Non operative treatment involves a prolonged period of immobility. This has the associated risks of deep venous thrombosis and lower respiratory tract infection. In addition, this method of treatment may lead to loss of muscle mass and prolong pain during healing. When considering surgical fixation the main obstacle encountered is adequate proximal fragment purchase, whilst avoiding the femoral stem and not disrupting the cement mantle. The target area between the stem and the inner surface of the femoral component in a 50 mm Birmingham implant is 17.2 mm. This is large enough to easily accommodate the threads of a 6.5 mm Richards screw. Placement of a 12.7 mm Compression Hip Screw (Smith and Nephew, Memphis, Tenn) and side plate construct would be technically challenging and risk disruption of the cement mantle. Other technical considerations include an acceptable reduction so as to avoid edge loading and adverse wear.
S.A. Brennan et al. / Injury, Int. J. Care Injured 44 (2013) 263–265
264
Fig. 3. Post-operative antero-posterior radiograph. Fig. 1. Antero-posterior view radiograph showing periprosthetic fracture.
Fig. 2. Lateral radiograph showing periprosthetic fracture.
Cannulated screws have been used successfully to treat mid-cervical, basi-cervical and inter-trochanteric neck of femur fractures (Table 1).8–10 If the fracture is intra-capsular and grossly displaced however this method should be avoided because avascular necrosis of the head remnant may result in early failure.11 Inter-trochanteric fractures have also been managed successfully with a blade plate, reversed distal femoral locking plates and proximal femoral locking plates.12–15 These methods of fixation require extensive dissection with increased resultant blood loss when compared to cannulated screws. In addition to this the
Fig. 4. Post-operative lateral radiograph.
insertion of a blade plate adjacent a resurfacing is technically demanding and there is potentially reduced hold on the proximal fracture fragment. Sub-trochanteric fractures have been treated using a reconstruction nail, contoured AO DCP and more recently trochanteric entry point cephallo-medullary nails.16–18 The DCP is an attractive option if an intramedullary nail is likely to cause further comminution, achieve inadequate fixation in the femoral neck or if the fixed angulation of the locking screws within the nail is
Table 1 Summary of publications. Author
Year
Journal
No. of cases
Fracture location
Treatment
Cumming Aning16 Cossey6 Morgan7 Weinrauch12 Kutty8 Merredy9 Orpen13
2003 2005 2005 2008 2008 2009 2009 2009
JBJS (Br) Injury J Arthroplasty Injury extra JBJS (Am) JBJS (Br) Injury extra Injury extra
1 1 7 2 1 1 1 2
Conservative Reconstruction nail Conservative Conservative Blade plate Cannulated screws Cannulated screws Distal femoral locking plate
Zustin11 Whittingham-Jones17 Baxter14 Lein10 Silk15 Peskun18
2009 2010 2010 2010 2011 2012
Acta Orthopaedica J Arthroplasty Hip International Unfallchirurg Injury extra J Arthroplasty
1 1 1 1 1 2
Subcapital Sub-trochanteric Undisplaced neck of femur Inter-trochanteric Inter-trochanteric Mid cervical Basi-cervical (a)Inter-trochanteric (b)Reverse oblique per-trochanteric Mid-cervical Sub-trochanteric Inter-trochanteric Inter-trochanteric Intra-trochanteric Inter-trochanteric Sub-trochanteric
5
Cannulated screws DCP plate Distal femoral locking plate AO Lag screws Proximal femoral locking plate Cephallo-medullary nail
S.A. Brennan et al. / Injury, Int. J. Care Injured 44 (2013) 263–265
precluded by the stem of the resurfacing arthroplasty. An intramedullary nail is however biomechanically favourable to a plate and is a load sharing construct. In addition to this it can be inserted in a minimally invasive manner with little blood loss. Conclusion Revising the hip to a long stemmed femoral component negates the benefits of conservation of femoral bone stock in the young patient and involves removing an otherwise well aligned and fixed implant. Traumatic femoral neck fractures involving hip resurfacing prostheses may be treated surgically without revision with a good functional outcome. Conflict of interest statement The authors declare that they have no conflict of interest. References 1. Kohan L, Field CJ, Kerr DR. Early complications of hip resurfacing. Journal of Arthroplasty 2012. [Epub ahead of print, Apr 13]. 2. Marker DR, Seyler TM, Jinnah RH, Delanois RE, Ulrich SD, Mont MA. Femoral neck fractures after metal-on-metal total hip resurfacing: a prospective cohort study. Journal of Arthroplasty 2007;22(7 Suppl. 3):66. 3. Anglin C, Masri BA, Tonetti J, Hodgson AJ, Greidanus NV. Hip resurfacing femoral neck fracture influenced by valgus placement. Clinical Orthopaedics and Related Research 2007;465:71. 4. Shimmin AJ, Back D. Femoral neck fractures following Birmingham hip resurfacing: a national review of 50 cases. Journal of Bone and Joint Surgery British Volume 2005;87:463. 5. Cumming D, Fordyce MJ. Non-operative management of a peri-prosthetic subcapital fracture after metal-on-metal Birmingham hip resurfacing. Journal of Bone and Joint Surgery British Volume 2003;85(September (7)):1055–6.
265
6. Cossey AJ, Back DL, Shimmin A, Young D, Spriggins AJ. The nonoperative management of periprosthetic fractures associated with the Birmingham hip resurfacing procedure. Journal of Arthroplasty 2005;20(April (3)): 358–61. 7. Morgan D, Myers G, O’Dwyer K, Thomas AM. Intertrochanteric fracture below Birmingham Hip Resurfacing: successful non-operative management in two cases. Injury Extra 2008;39–9:313–5. 8. Kutty S, Pettit P, Powell JN. Intracapsular fracture of the proximal femur fracture after hip resurfacing treated by cannulated screws. Journal of Bone and Joint Surgery British Volume 2009;91(August (8)):1100–2. 9. Mereddy P, Malik H, Geary N. Peri-prosthetic fracture of femur following metalon-metal Birmingham hip resurfacing treated by internal fixation. Injury Extra 2008. 10. Lein T, Schlee J, Kothe M, Moritz F, Wubtaye DT. Periprosthetic intertrochanteric fracture of the femur following articular resurfacing of the hip joint: treatment with lag screw osteosynthesis. Unfallchirurg 2010;113(November (11)): 944–50. 11. Zustin J, Winter E. Failed internal fixation due to osteonecrosis following traumatic periprosthetic fracture after hip resurfacing arthroplasty. Acta Orthopaedica 2009;80(December (6)):666–9. 12. Weinrauch P, Krikler S. Proximal femoral fracture after hip resurfacing managed with blade-plate fixation. A case report. Journal of Bone and Joint Surgery 2008;90(June (6)):1345–7. 13. Orpen NM, Pearce O, Deakin M, Keys RI. Internal fixation of trochanteric fractures of the hip after surface replacement. Injury Extra 2009;40: 32–5. 14. Baxter JA, Krkovic M, Prakash U. Intertrochanteric femoral fracture after hip resurfacing managed with a reverse distal femoral locking plate: a case report. Hip International 2010;20(October–December (4)):562–4. 15. Silk G, Sangster M, Sandhu H. Internal fixation of trochanteric fracture following hip resurfacing. Injury Extra 2011;42:183–5. 16. Aning J, Aung H, Mackinnon J. Fixation of a complex comminuted proximal femoral fracture in the presence of a Birmingham hip resurfacing prosthesis. Injury 2005;36(September (9)):1127–9. 17. Whittingham-Jones P, Charnley G, Francis J, Annapureddy S. Internal fixation after subtrochanteric femoral fracture after hip resurfacing arthroplasty. Journal of Arthroplasty 2010;25(February (2)):334. 18. Peskun CJ, Townley JB, Schemitsch EH, Waddell JP, Whelan DB. Treatment of periprosthetic fractures around hip resurfacings with cephalomedullary nails. Journal of Arthroplasty 2012;27(March (3)):494.