Identify high-risk patients, surgical factors to prevent intraoperative femur fractures
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Key takeaways:
- Surgeons should aim to prevent intraoperative femur fractures by identifying high-risk patients and surgical risk factors.
- Sound change during broaching is key to know when to stop.
KOLOA, Hawaii — With intraoperative femur fractures on the rise, surgeons should aim to prevent these fractures from occurring by identifying high-risk patients and surgical risk factors, according to a presenter here.
“Patient risk factors [include] osteopenia; females of older age, that is usually due to osteopenia; and certain anatomies will place the patient at risk as well, such a protrusio [acetabuli] or femoral osteolysis,” Donald S. Garbuz, MD, FRCSC, MHSc, professor and head of the division of lower limb reconstruction in the department of orthopedics at the University of British Columbia, said in his presentation at Orthopedics Today Hawaii.
He added surgical risk factors include the use of cementless implants, taper wedge designs, and minimally invasive and anterior-based approaches.
“[Fracture] can happen at any time,” Garbuz said. “It can happen during the exposure, especially in revision surgery. It can happen when you are broaching the femur, or often it happens when you are putting the stem in, and it is usually the final hit.”
He cautioned surgeons to be wary of the stiff hip during exposure, to always perform a gentle dislocation, consider an in-situ neck cut and avoid high torsional stresses that could break the femur.
“To prevent [fracture], I like to get an adequate exposure,” Garbuz said. “I want to see 360° around the femur. I do not want to just see a little bit of femur and miss that neck cut. Those early postoperative fractures are almost all missed intraoperative fractures.”
When broaching, Garbuz said he prefers to use manual instruments with firm, steady blows. He added that if the broach or implant fails to advance or there is a sound change, to stop.
“I know in the United States, certainly, these automated impactors are popular now,” Garbuz said. “I do not use them. They are noisy, and I cannot hear that sound change and, for me, that is key.”
If a fracture occurs during broaching, Garbuz said to expose the distal extent of the fracture, put cerclage wires distal to the fracture and finish the preparation. He added that once a fracture is present, make sure it does not propagate and, if it does, have a low threshold for converting to distal fixation. Surgeons should suspect a fracture if the stem goes below the broach level or if there is a sudden change of resistance when implanting the stem.
“Same treatment if the stem goes in and it goes too far: remove the stem, wire it and you can reinsert the stem as long as it is not well distal to the lesser trochanter,” Garbuz said. “If it goes below the lesser trochanter, you need to go to distal fixation.”
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Garbuz DS. Preventing intraoperative fractures. Presented at: Orthopedics Today Hawaii; Jan. 12-16, 2025; Koloa, Hawaii.
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