Preventing and Managing Intraoperative Fractures and Perforations in Hip Arthroplasty

Abstract

Intraoperative perforation of the femur, a serious complication of hip arthroplasty, encompasses a broad spectrum — from a simple hole in the bone to a displaced fracture with an unstable prosthesis. Although some intraoperative perforations are managed routinely, others are disastrous and often associated with greater morbidity, mortality, increased blood loss, and poor clinical outcome. Appropriate recognition, including an awareness of preoperative risk factors, is paramount to the successful management of these complications. We have found the S-ROM (DePuy Orthopaedics Inc., Warsaw, Ind) prosthesis safe in the prevention of cortical perforation in high-risk patients and effective in managing intraoperative perforation and fracture when it occurs.

Numerous series describe intraoperative fracture and femoral perforation with varied rates depending on the operative setting, surgical technique, and the implant used. The increasing use of uncemented implants has been accompanied by an increased rate of femoral fracture. In a series of primary total hip replacements (THR) from the Mayo Clinic, the intraoperative fracture rate was 0.3% with cemented implants and 5.4% with cementless implants. The rate increased to 20.9% in cementless revision THR.¹ In a comparison of cemented versus uncemented revision procedures, Morrey and Kavanagh² noted a 18% rate of intraoperative fracture with uncemented implants with three of 15 fractures going onto failure, compared to a 3% fracture rate in cemented revisions with one of the three fractures ultimately resulting in failure.

The rate of perforation appears highest with extensively porous-coated implants. Egan and DiCesare³ reported a 16% perforation and a 25% overall fracture rate in a series of 135 revisions with a fully porous-coated, straight cobalt-chrome stem. They found an increased rate of fracture with stems 200 mm in length. Issack et al⁴ noted a reduced rate of intraoperative fracture in a series of 175 femoral revisions using an extensively porous-coated stem modified with a distal slot and flutes. Only nine fractures and four perforations were reported, with a trend toward increased fracture rate with increased stem length and diameter, which was not statistically significant. In a series of 187 revisions using a fully porous-coated implant, Paprosky et al⁵ reported an 8.8% rate of fracture during stem insertion; however, another 5.9% were noted to have intraoperative fracture or perforation during the removal of cement. In a recent series of revision procedures, Meek et al⁶ reported an intraoperative fracture rate of 30% using an uncemented diaphyseal fitting stem. Fracture occurred most commonly during insertion of trial or final components; however, nine of 11 cortical perforations occurred during cement removal. Although the intraoperative fracture rate appeared significant, no association between intraoperative fracture and poor clinical or radiographic results was found. In fact, intraoperative fracture was associated with bone ingrowth, and over- or line-to-line reaming was associated with a higher incidence of unstable fibrous union.

Past reports of intraoperative fracture have not always carried a good prognosis. Fitzgerald et al⁷ noted a significant rate of prosthetic loosening, four of 40 cases, when intraoperative fractures associated with an uncemented implant were treated with the use of cerclage wires or Parham bands and bone grafting. In a series of 14 patients with perforation of the femur during cemented THR, Talab et al⁸ reported a high incidence of complications including four postoperative fractures and eight revisions, and nearly all patients experienced chronic pain. Most of these cases, however, were either unrecognized or untreated intraoperatively.

Cemented implants are not without significant fracture risk, particularly if cement extravasation occurs through an unrecognized intraoperative perforation. Multiple reports in the literature implicate cement extrusion through areas of cortical perforation as a cause of postoperative fracture.^8-13 Possibly the most common and potentially disastrous setting for intraoperative cortical perforation occurs in revision surgery during cement removal or in the process of femoral reaming after the incomplete removal of cement.

Risk Factors

Numerous preoperative risk factors associated with intraoperative fracture and femoral perforation exist, including preoperative bone loss in the form of osteolysis or osteoporosis, previous surgery, previous fracture, and femoral deformity. Femoral deformity is a complex problem and encompasses a broad spectrum, including a low femoral cortex to canal ratio, prior malunion, bowing, and varus remodeling associated with loose implants.^1,3,6,7,14 Certain disease processes associated with significant femoral deformity such as developmental dysplasia of the hip and juvenile rheumatoid arthritis may also predispose a patient to perforation and fracture. Conditions associated with osteopenia and bone fragility including rheumatoid arthritis and Paget’s disease also predispose patients to intraoperative fracture and perforation. Gender has been controversial in past reports, with some studies demonstrating an increased risk of intraoperative fracture in women. A history of anemia or thalassemia has also been suggested to increase the risk of intraoperative fracture, and care should be taken during femoral preparation in patients with these conditions.¹⁵

Intraoperative factors predisposing patients to fracture and perforation include under-reaming of the cortex, use of longer and larger stem implants, and revision arthroplasty with difficult removal of cemented components.^6,14,16

Although many of these factors may be present in the revision setting, a history of previous surgeries also increases the potential for intraoperative fracture and perforation. Previous osteotomy or fracture results in altered femoral morphology, as well as areas of brittle sclerotic bone or callus, that may deflect instrumentation leading to fracture or perforation.¹⁵ Fracture may result from difficult removal of prior fixation devices, while screw tracts can act as both stress risers and avenues for the escape of both reamers and components. In Talab’s⁸ series of 14 femoral perforations, 57% of patients had undergone previous osteotomy or internal fixation for fracture. Total hip replacement in the setting of previous proximal femoral fracture or osteotomy with retained internal fixation devices is a procedure with a high risk of intraoperative perforation or fracture. In a series of 19 patients, Zhang et al¹⁷ reported a 32% incidence of intraoperative fracture with the use of a standard prosthesis mainly inserted with cement.

Treatment

Management of intraoperative fracture varies depending on three important fracture characteristics: location, configuration, and stability. Isolated perforations that are recognized intraoperatively and respected during femoral preparation may be treated with morselized graft and, occasionally, cerclage distal to the fracture to prevent propagation. A cemented prosthesis may still be used in isolated perforations if care is taken to expose the defects and prevent extravasation that may lead to pain or late fracture.¹⁸

When a perforation propagates resulting in a nondisplaced linear fracture in the proximal metaphysis or proximal diaphysis, cerclage wires are required up to and beyond the distal extent of the fracture. The cement mantle may be compromised in this setting and therefore a cementless prosthesis should be implemented. The prosthesis should bypass the defect by at least 2.5 cortical diameters, and nondisplaced fractures extending into the distal diaphysis and distal metaphysis are frequently augmented with strut allografts for increased stability.^19,20

Treatment recommendations for displaced and unstable fractures vary based on fracture location. Displaced proximal fractures may be treated with simple cerclage, whereas displaced fractures extending into the diaphysis require a longer stem that gains purchase within the diaphysis and usually strut allograft augmentation, as well. Displaced unstable intraoperative fractures occurring in the distal diaphysis and metaphysis can be difficult to treat, often requiring open reduction and internal fixation, struts, and other suitable implants.^14,18,19 Finally, fractures involving severe comminution and bone loss of the entire proximal femur are beyond the scope of this discussion; however, treatment options include diaphyseal locking components, megaprostheses, or prosthetic allograft composites. Wide exposure and the judicious use of intraoperative radiographs or fluoroscopy are required when an intraoperative fracture is suspected.

Prevention and Management of Cortical Perforation

The modular S-ROM prosthesis (DePuy Orthopaedics Inc., Warsaw, Ind) is an excellent solution for the prevention and management of femoral cortical perforation and intraoperative fracture. The modularity of the prosthesis allows a precise fit and appropriate sizing of the proximal metaphysis, even when obscured by malunion and hypertrophic callus. Proximally, the implant is porous coated for biologic fixation with the metaphysis and, distally, the stem’s fluted design allows for initial fixation within the diaphysis and promotes rotational stability when bone stock is compromised.^15,21 In addition, the distally fluted stem is more compliant and less rigid than fully coated implants, which may reduce the bone strain and incidence of stem tip fractures during component insertion.^4,22

Figure: An 80-year-old woman presented with intertrochanteric nonunion 9 months following internal fixation (A). Despite multiple risk factors for cortical perforation and intraoperative fracture, the patient undergoes uncomplicated THR with a standard S-ROM femoral component and is pain free with stable bony ingrowth at 1 year (B).

The S-ROM system uses reaming exclusively in preparation of the proximal femur. Whether faced with osteopenia, defects from previous fixation devices, or a sclerotic nonunion site, milling appears to be safer than broaching for avoiding the creation or propagation of fractures intraoperatively. Variable stem lengths for bypassing screw holes and bone defects and multiple neck lengths for replacing proximal bone loss are also useful in difficult revision and conversion cases.²¹ Also, use of the S-ROM prevents the potential extravasation of cement through screw holes and fracture lines, as well as the risks associated with cement pressurization. This may reduce the operative difficulty of the procedure, as well as the potential for persistent nonunion caused by cement, resulting in possible trochanteric nonunion or postoperative periprosthetic fracture.²³

The use of the S-ROM may be limited in patients with severe proximal femoral bone loss and limited metaphyseal bone remaining for ingrowth unless the prosthesis is combined with an allograft and inserted with cement.^24,25 In some patients, a diaphyseal-locking, extensively porous-coated implant may be indicated.⁵

Previous reports have demonstrated a good track record for the S-ROM in the prevention of cortical perforation during complex hip arthroplasty (Figure).^21,22,24-27 In a series of 91 revisions, Cameron²² noted two perforations during cement removal, one calcar split and four anterior femoral perforations near the tip of the stem. Although the anterior perforations required re-revision, they all occurred with the use of a straight stem and no cases of perforation with the introduction of curved stems. Chandler et al²⁵ reported on the use of the S-ROM in 52 complex revisions. Only six cases of perforation were present, two at the tip of long curved stems, which were treated with protected weight bearing and healed uneventfully, and four during cement removal, which were bypassed. Thirteen patients were noted to have nondisplaced intraoperative calcar fractures during impaction of the metaphyseal sleeve. These patients were treated with cerclage wires and also went on to uneventful healing. A recent large series by Christie et al²⁷ demonstrated a low rate of intraoperative fracture with the use of the S-ROM in primary THR. One calcar fracture occurred in 175 consecutive cases and the low rate of complication included only one femoral revision at an average follow-up of 5.3 years.

The management of intraoperative femoral perforation during hip arthroplasty requires prompt recognition and appropriate assessment of the extent of the complication. Assessment begins in the preoperative period with recognition of significant risk factors, including previous surgery, retained hardware, the need for cement removal, bone loss, and systemic medical conditions, as well as selection of suitable components. The S-ROM prosthesis offers several advantages in the prevention and treatment of intraoperative perforation in high-risk patients.

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Authors

Drs Talmo and Bono are from the New England Baptist Hospital, Boston, Mass.