The Journal of Bone and Joint Surgery (American). 2010;92:404-410.
doi:10.2106/JBJS.H.01113
© 2010 The Journal of Bone and Joint Surgery, Inc.
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Morphologic Analysis of Periprosthetic Fractures After Hip Resurfacing Arthroplasty

Jozef Zustin, MD1, Matthias Krause1, Stefan Breer1, Michael Hahn, PhD1, Christoph von Domarus, MD1, Wolfgang Rüther, MD1, Guido Sauter, MD1, Michael M. Morlock, PhD2 and Michael Amling, MD, MBA1

1 Departments of Pathology (J.Z. and G.S.), Orthopaedics (W.R.), Trauma, Hand and Reconstructive Surgery (M.A.), and Osteology and Biomechanics (M.K., S.B., M.H., C.v.D., and M.A.), University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. E-mail address for J. Zustin: j.zustin{at}uke.uni-hamburg.de. E-mail address for M. Amling: amling{at}uke.uni-hamburg.de
2 Biomechanics Section, Technische Universität Hamburg-Harburg (TUHH), Denickerstrasse 15, 21073 Hamburg, Germany

Investigation performed at University Medical Center Hamburg-Eppendorf and the University of Technology (TUHH), Hamburg, Germany

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Biomet Orthopaedics (Warsaw, Indiana), Corin Medical (Cirencester, United Kingdom), DePuy Orthopaedics International (Leeds, United Kingdom), Smith and Nephew (London, United Kingdom), and Zimmer (Warsaw, Indiana). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Background Periprosthetic fractures have long been recognized as one of the major complications of hip resurfacing arthroplasty. The objective of this study was to develop a systematic and morphologic classification of the fracture mode based on pathogenesis.

Methods One hundred and seven retrieved specimens consisting of the femoral remnant and the femoral component of a total hip resurfacing arthroplasty that had failed as a result of a periprosthetic fracture were analyzed with regard to the morphologic failure mode. The location of the fracture line was used to differentiate the fractures. The fractures were also classified histopathologically as acute biomechanical, acute postnecrotic, or chronic biomechanical.

Results Fifty-nine percent (sixty-three) of the fractures occurred within the bone inside the femoral component. Fifty-one percent (fifty-five) of the fractures were classified morphologically as acute postnecrotic; 40% (forty-three), as chronic biomechanical; and 8% (nine), as acute biomechanical. Acute biomechanical fractures were found exclusively in the femoral neck and occurred earlier (mean time [and standard deviation] between implantation and revision, 41 ± 57 days) than acute postnecrotic fractures (mean time between implantation and revision, 149 ± 168 days; p = 0.002) or chronic biomechanical fractures (mean time between implantation and revision, 179 ± 165 days; p = 0.001). The latter two fracture types both occurred predominantly in the bone inside the femoral component.

Conclusions Three distinct fracture modes were characterized morphologically. Osteonecrosis was the most frequent cause of fracture-related failures. We suggest that an intraoperative mechanical injury of the femoral neck such as notching and/or malpositioning of the femoral component might lead to changes in the loading pattern or in the resistance to fracture of the femoral neck and may result in both acute and chronic biomechanical femoral neck fractures. These findings may serve as feedback information for the surgeon and possibly influence future therapeutic strategies.


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