Abstract
Introduction
Intraoperative periprosthetic femoral fractures (IOPFF) lead to reduced implant survival. A deeper understanding of predictors enables surgeons to modify techniques and patient selection to reduce the risk of IOPFF. The aim of this study was to estimate predictors of IOPFF and each anatomical subtype (calcar crack, trochanteric fracture, femoral shaft fracture) during primary THA.
Methods
This retrospective cohort study included 793823 primary THAs between 2004 and 2016. Relative risks for patient, surgical and implant factors are estimated for any IOPFF fracture and for all anatomical subtypes of IOPFF.
Results
Patient factors significantly increasing the risk of fracture were: female gender, American Association of Anaesthesiologists (ASA) grade 3 to 5, pre-operative diagnosis including: avascular necrosis of the hip (AVN), previous trauma, inflammatory disease, paediatric disease and previous infection. Overall risk of IOPFF associated with age was greatest in patients below 50 years and above 80 years. Risk of any fracture reduced with computer guided surgery (CGS) and in non-NHS hospitals. Non-posterior approach's increased the risk of shaft and trochanteric fracture only. Cementless implants only significantly increased the risk of calcar cracks and shaft fractures and not trochanteric fractures.
Conclusions
Fracture risk increases in patients less than 50 and older than 80, females, ASA grade 3 to 5 and indications other than primary osteoarthritis. Large cumulative reduction in IOPFF risk may occur with use of cemented implants, posterior approach and CGS. IOPFF may be further reduced by future developments in cementless stem implantation and non-posterior approaches which reduce the intraoperative strain placed on the femora.
