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 Adult Hip Reconstruction Test 6: Total Hip Arthroplasty Techniques
CME 1: January, February, March 2004
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The Journal of Bone and Joint Surgery (American) 86:480-485 (2004)
© 2004 The Journal of Bone and Joint Surgery, Inc.

Intraoperative Fracture of the Femur in Revision Total Hip Arthroplasty with a Diaphyseal Fitting Stem

R.M. Dominic Meek, MBChB, MD, FRCS(Tr and Orth)1, Donald S. Garbuz, MD, MHSc, FRCSC2, Bassam A. Masri, MD, FRCSC2, Nelson V. Greidanus, MD, MPh, FRCSC2 and Clive P. Duncan, MD, MSc, FRCSC2

1 Southern General Hospital, 1345 Govan Road, Glasgow, Scotland. E-mail address: rmdmeek{at}doctors.org.uk
2 Division of Lower Limb Reconstruction and Musculoskeletal Oncology, Department of Orthopaedics, University of British Columbia, 910 West Tenth Avenue, Third Floor, Vancouver, BC VZ1 1M9, Canada

Investigation performed at the Division of Lower Limb Reconstruction and Oncology, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada

In support of their research or preparation of this manuscript, one of the authors (R.M.D.M.) received grants or outside funding from the Charnley Trust and the British Orthopaedic Association Wishbone Trust. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: In revision total hip arthroplasty, intraoperative split fractures and cortical perforation fractures are becoming a more common concern with the increasing use of diaphyseal fitting cementless stems. The purpose of this study was to evaluate the risk factors and frequency of intraoperative fractures with the use of these stems and their effect on radiographic and functional outcomes.

Methods: We performed a retrospective case-control study of 211 consecutive patients who had undergone revision hip arthroplasty with a diaphyseal fitting cementless stem between December 1998 and March 2002. Sixty-four patients sustained an intraoperative fracture of the femur. One hundred and fifteen patients were followed for a minimum of two years; function was analyzed with self-administered outcome questionnaires, and radiographs were evaluated for evidence of bone ingrowth into the femoral stem.

Results: Risk factors associated with an intraoperative fracture were a substantial degree of preoperative bone loss, a low femoral cortex-to-canal ratio, underreaming of the cortex, and the use of a large-diameter stem. The majority of the diaphyseal undisplaced linear fractures occurred at the distal end of an extended trochanteric osteotomy during stem insertion. Fracture due to cortical perforation occurred most often during cement removal. These intraoperative fractures had no significant effect on the functional outcome or radiographic evidence of bone ingrowth.

Conclusions: There was a surprisingly high rate of intraoperative femoral fractures associated with the use of a diaphyseal fitting stem in revision total hip arthroplasty. Identification of risk factors such as preoperative bone loss and a low cortex-to-canal ratio may permit planning to avoid such fractures. However, the final functional and radiographic outcomes appear to have been unaffected by the fracture when it had been managed appropriately.

Level of Evidence: Prognostic study, Level II-1 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.


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