Slideshow
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Figure 1. Anteroposterior radiograph of hip after total hip arthroplasty.
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Figure 2. Anteroposterior radiograph of hip taken in the ED.
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Figure 3. Lateral radiograph of pelvis taken in the ED.
A 52-year-old man presents to the emergency department (ED) with severe right hip pain after falling while getting out of the pool. He notes that he underwent a total hip arthroplasty (THA) with anterior approach 1 month prior to the fall. On physical examination, the patient has significant pain with any motion of the right hip. A radiograph of the pelvis taken immediately after THA is obtained (Figure 1) and is compared with radiographs taken during the ED visit (Figure 2 and 3).
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The patient is diagnosed with a periprosthetic hip fracture with a subsided loose femoral component. The most common reasons for revision surgery after a primary THA are wound-related complications (49%), periprosthetic fracture (25%), and pain (18%).1
Treatment of periprosthetic fractures is determined by the fracture location. Proximal fractures (greater trochanter fractures) that are not displaced can be treated nonoperatively with protected weight-bearing and avoiding hip abduction. Displaced greater trochanter fractures are often treated with a trochanter plate with or without cerclage cables.2
Fractures at the midpoint of the prosthesis that extend into the diaphysis (as seen with this patient) often cause the femoral prosthesis to subside and become unstable. These fractures require explant of the loose prosthesis with revision of the femoral component to a longer cement-less stem that bypasses the fracture line. Cerclage wires, 360 degree circumferential wires, are often used proximally to prevent further displacement of the fracture fragments.2,3
Fractures that occur distal to a well-fixed femoral prosthesis can be fixed with open reduction and internal fixation with a plate.2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopaedics for Physician Assistants.
References
1. Ledford CK, Perry KI, Hanssen AD, Abdel MP. What are the contemporary etiologies for revision surgery and revision after primary, noncemented total hip arthroplasty? J Am Acad Orthop Surg. 2019;27(24):933-938. doi:10.5435/JAAOS-D-17-00842
2. Marsland D, Mears SC. A review of periprosthetic femoral fractures associated with total hip arthroplasty. Geriatr Orthop Surg Rehabil. 2012;3(3):107-120. doi:10.1177/2151458512462870
3. Agarwala S, Menon A, Chaudhari S. Cerclage wiring as an adjunct for the treatment of femur fractures: series of 11 cases. J Orthop Case Rep. 2017;7(4):39-43. doi:10.13107/jocr.2250-0685.842
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