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The Journal of Bone and Joint Surgery 78:1206-13 (1996)
© 1996 The Journal of Bone and Joint Surgery, Inc.

Periprosthetic Fracture of the Acetabulum after Total Hip Arthroplasty*

CHARLES A. PETERSON II, M.D.{dagger} and DAVID G. LEWALLEN, M.D.{ddagger}, ROCHESTER, MINNESOTA

Investigation performed at the Mayo Clinic and Mayo Foundation, Rochester


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Eleven patients who had sustained a periprosthetic fracture of the acetabulum at a mean of 6.2 years (range, one month to thirteen years) after a total hip arthroplasty were managed at our institution between 1985 and 1991. Five patients had a fracture of the medial wall; three, a fracture of the posterior column; two, a transverse fracture; and one, a fracture of the anterior column. Six fractures were displaced by two millimeters or more. Eight fractures were caused by blunt trauma or a fall, and three occurred spontaneously. A fracture was classified as type 1 if the acetabular component was clinically and radiographically stable (eight patients) and as type 2 if the component was unstable (three patients). One patient, who had a displaced type-2 fracture of the posterior column, died of an associated intrapelvic vascular injury. The other two patients who had a type-2 fracture were managed with revision of the acetabular component without supplemental plate fixation, immediately after the diagnosis of the fracture. The eight patients who had a type-1 fracture initially were managed with limitation of weight-bearing or modification of activity; in six of these patients, the fracture united without additional treatment. The ten surviving patients were followed for a mean of sixty-two months after the fracture. Eight of these patients—including four in whom a type-1 fracture had united after non-operative treatment—had a revision of the acetabular component because of pain, loosening, or non-union by the time of the most recent follow-up. Two patients (one of whom had a type-1 fracture and the other, a type-2 fracture) had multiple revisions of the acetabular component; both had supplemental internal fixation with a plate. All ten patients ultimately had a stable, functioning prosthesis. We conclude that periprosthetic acetabular fractures are associated with a poor prognosis with regard to the survival of the acetabular component but that it is possible to achieve union and to salvage a functional prosthesis in patients who have sustained such a fracture.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
A periprosthetic fracture is a challenging complication of total hip arthroplasty. As the function of an implant relies heavily on a stable bone-cement or bone-prosthesis interface, a fracture that disrupts this interface may have grave implications for the function and survival of the component. Although periprosthetic femoral fractures have been reported increasingly after total hip arthroplasty1-3,8, periprosthetic acetabular fractures have been noted only rarely6,7,9. As a result, the initial treatment of the fracture, the potential for union of the fracture, the implications for survival of the acetabular component, and the treatment of complications remain unclear. Following the death of one of our patients as the result of such a fracture, we reviewed our experience with these injuries in an attempt to clarify these issues.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 

Design of the Study
Sixteen patients who had sustained a periprosthetic acetabular fracture after a total hip arthroplasty were identified by means of a retrospective analysis of the Total Joint Registry at the Mayo Clinic for the years 1971 to 1991. The arthroplasties in these patients represented 0.07 per cent of the 23,850 total hip arthroplasties (18,630 primary and 5220 revision procedures) that were performed at our institution during this period. All clinical records and radiographs for these sixteen patients then were reviewed by one of us (C. A. P., II). Three patients who had sustained a pathological fracture secondary to a neoplasm and two others who had been followed clinically and radiographically for less than twenty-four months were excluded from the study. Patients who had atraumatic pelvic discontinuity secondary to osteolysis in association with loosening, migration, or wear of the acetabular component were excluded from the initial search of the database.

Patients
Eleven patients who had sustained a periprosthetic fracture of the acetabulum at a mean of 6.2 years (range, one month to thirteen years) after a total hip arthroplasty were managed at our institution between 1985 and 1991. The patients included six women and five men who had been a mean of sixty-six years old (range, fifty-four to seventy-one years old) at the time of the fracture (Table I). Ten of the eleven patients had had the index total hip arthroplasty at our institution.


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  		TABLE I DATA ON THE PATIENTS

 
The primary diagnosis that had led to the initial total hip arthroplasty had been degenerative osteoarthrosis in three patients; congenital dysplasia of the hip in four; and rheumatoid arthritis, multiple epiphyseal dysplasia, non-union of an intertrochanteric femoral fracture, and a displaced fracture of the femoral neck in one patient each.

Nine of the acetabular components that were in place at the time of the fracture—including six all-polyethylene cups and three metal-backed cups—had been inserted with cement. The remaining two components were designed for ingrowth of bone and had been inserted without cement and fixed with screws. The over-all mean outer diameter of the cup was forty-nine millimeters (range, forty to fifty-six millimeters).

Four patients sustained the fracture about an acetabular component that had been inserted in a revision procedure. Two of these patients had had multiple acetabular revisions. Four patients had a total hip prosthesis in place in each hip at the time of the fracture. Five patients had had a previous operation on the hip before arthroplasty. However, only one of these procedures—a Salter innominate osteotomy for congenital dysplasia of the hip—had involved the acetabulum. One patient had sustained a previous pelvic injury (an extra-acetabular Malgaigne fracture) that had healed completely before the acetabular fracture occurred.

Radiographs that had been made after the arthroplasty and at a mean of nineteen months (range, one to ninety-four months) before the fracture were available for the ten patients who had had the index arthroplasty at our institution. Three patients had had a radiolucent line that was less than two millimeters wide at the bone-cement interface of the acetabular component before the fracture, but no patient had had pain or other symptoms of loosening. No patient had had evidence of osteolysis or migration of the component before the fracture, and no patient had evidence of osteolysis immediately after the fracture.

The etiology of the fracture was a fall or blunt trauma (such as that sustained in a motor-vehicle accident) in four patients each. In the remaining three patients, the etiology was unknown and the fracture was diagnosed on the basis of radiographs that were made because of the onset of pain without notable antecedent trauma. In two of these patients, the fracture had occurred between eight and nine years postoperatively. In the third, the fracture was noted two months after the insertion of an acetabular component with cement; a review of the operative report as well as the immediate postoperative anteroposterior radiographs of the pelvis and lateral radiographs of the hip did not reveal evidence of either occult pelvic discontinuity or intraoperative acetabular fracture.

Each fracture was diagnosed and characterized on the basis of plain radiography, tomography, operative findings, or a combination of these. Anteroposterior radiographs of the pelvis and lateral radiographs of the hip were the only diagnostic studies available for eight patients; supplemental iliac and obturator oblique radiographs or tomograms were available for the other three. Three fractures could not be characterized fully until the time of operative exploration.

The fractures were classified according to the system of Letournel, which was modified to include a category for fractures of the medial wall of the acetabulum. These fractures, which generally are seen only in patients who have had an arthroplasty, involve only the medial surface of the acetabulum while excluding the anterior and posterior columns and the peripheral walls. If only anteroposterior radiographs of the pelvis and lateral radiographs of the hip were available and the patient was to be managed non-operatively, the fracture was classified as a fracture of the medial wall unless the anterior column (the iliopectineal line) or the posterior column (the ilioischial line and the ischial ramus) was disrupted visibly. Five fractures of the medial wall, three fractures of the posterior column, two transverse fractures, and one fracture of the anterior column were identified with use of this system. Six fractures were displaced by two millimeters or more (mean displacement, seven millimeters; range, two to twenty millimeters).

The fractures also were classified on the basis of the stability of the acetabular component. The fracture was classified as type 1 if the component was radiographically stable—that is, there was no change in the position of the component compared with that seen on radiographs made before the fracture (if available)—and a gentle passive range of motion of the hip caused little or no pain. The fracture was classified as type 2 if the acetabular component was obviously displaced or radiographically loose and there was notable pain with any motion of the hip. There were eight type-1 and three type-2 fractures.

One patient who had a type-2 fracture died acutely because of laceration of the posterior branch of the internal iliac artery either by fracture fragments or by the screws that had been used for fixation of the cup without cement (Figs. 1-A, 1-B, and 1-C). Traumatic posteromedial displacement of the cup had occurred in association with a fracture-dislocation of the posterior column that had been sustained in a motor-vehicle accident. Despite emergency arteriography with embolization of the vessel after initial resuscitation in the emergency room, the patient died of multisystem organ failure secondary to a massive loss of blood.



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  		Figs. 1-A, 1-B, and 1-C: Case 1. Radiographs of a sixty-six-year-old man who sustained a displaced type-2 fracture of the posterior column. The acetabular component that was in place at the time of the injury had been inserted without cement and fixed with screws. Fig. 1-A: Anteroposterior radiograph of the pelvis, made immediately after the insertion of the acetabular component without cement.

 


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  		Lateral radiograph made immediately postoperatively.

 


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  		Anteroposterior radiograph made after the periprosthetic fracture, which was associated with laceration of the posterior branch of the internal iliac artery. The patient subsequently died secondary to a massive loss of blood.

 
The initial management of the ten surviving patients was based on the stability of the acetabular component. The eight patients who had a type-1 fracture first received non-operative treatment. Three of these patients were managed with non-weight-bearing for four to fourteen weeks followed by partial weight-bearing for six to twenty-four weeks; four, with immediate partial weight-bearing for six weeks to eighteen months; and one, with observation and modification of activity for eight weeks. No patient was managed with traction, prolonged bed rest, or a hip-spica cast.

The two patients who survived after a type-2 fracture had an immediate revision arthroplasty after the diagnosis of the fracture. The acetabular component was inserted with cement in one patient and was inserted without cement and fixed with screws in the other. Neither patient was managed with supplemental plate fixation.

Eight patients (including the two just mentioned) had a revision of the cup. Four of these patients had a conversion to a bipolar endoprosthesis; three, a revision without cement; and one, a revision with cement. Seven of the eight patients had supplemental autologous or allogeneic cancellous bone-grafting. Supplemental internal fixation was not used in any of the initial revision procedures.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
The ten patients who survived the fracture were followed for a mean of sixty-two months (range, twenty-seven to 112 months) after the fracture. Radiographic union was defined as the resolution of all previous fracture lines with bridging, remodeling callus. Clinical union was defined as the resolution of all pain during walking.

Six of the eight type-1 fractures united both clinically and radiographically after a mean of twenty weeks (range, six to forty weeks) of non-operative treatment. Delayed union or non-union, with loosening of the acetabular component, was noted at three and eight months in the other two patients who had such a fracture. Both patients subsequently were managed with revision of the component and bone-grafting. The fracture of the medial wall in one of these patients (Case 10) united with stability of the component, but the transverse fracture in the other patient (Case 11) did not unite and a second revision was performed with supplemental plate fixation.

One of the type-2 fractures united within three months after the initial acute revision of the acetabular component with cement. The other type-2 fracture, a transverse fracture, failed to unite after the initial acute revision without cement and was treated with an additional revision with cement and supplemental plate fixation.

Over-all, eight patients (six of whom had a type-1 fracture and two of whom had a type-2 fracture) had had a revision of the acetabular component after the fracture by the time of the latest follow-up. In addition to the four patients described earlier (two of whom had an acute revision because of a type-2 fracture and two of whom had a delayed revision because of a non-union or a delayed union of a type-1 fracture), four of the six patients in whom a type-1 fracture had united after the initial non-operative treatment ultimately had a revision of the acetabular component because of progressive pain and loosening. Union of the fracture was confirmed at the time of the operation.

The mean time from the fracture to the revision was fifteen months (range, zero to fifty-five months). Survivorship analysis, with failure defined as revision of the component or death of the patient in association with displacement of the cup, revealed only an 18 per cent over-all chance that the component that had been in place before the fracture would be in place five years after the fracture (Fig. 2).



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  		Survivorship curve, with failure defined as revision of the component or death of the patient in association with displacement of the cup, showing the survival of the acetabular component five years after periprosthetic fracture. The values in parentheses indicate the number of surviving components, and the dashed bars indicate 95 per cent confidence intervals.

 
Six of the eight patients who were managed with revision had a stable, functioning acetabular component by a mean of forty-two months (range, ten to sixty-three months) after the initial revision that was performed after the fracture. The initial revision failed in the other two patients, both of whom had a transverse fracture. In one of these patients (Case 2), the initial revision was performed immediately after the diagnosis of a type-2 fracture; in the other (Case 11), it was performed because a type-1 fracture had failed to unite after eight months of non-operative treatment. In both patients, the cup had been inserted without cement and used as a so-called internal plate; that is, the surgeon had attempted to achieve both stability of the fracture and fixation of the cup with use of the anchoring screws (Fig. 3-A). The two patients subsequently had migration of the cup, increased displacement of the fracture, and pain at eight and nineteen months after the revision (Fig. 3-B), and both were managed with an additional revision of the cup with supplemental plate-and-screw fixation and bone-grafting of the posterior column (Fig. 3-C). The acetabular component that was inserted during the additional revision was fixed with cement in one patient and without cement in the other. The latter patient needed a third revision (without cement) fifty-five months later because of painful, aseptic loosening despite union of the fracture. All eight patients had a stable, functioning prosthesis by a mean of thirty-six months (range, ten to fifty-nine months) after the latest revision.



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  		Figs. 3-A, 3-B, and 3-C: Case 2. Radiographs of a sixty-two-year-old woman who sustained a type-2 transverse periprosthetic fracture that involved the anterior and posterior columns. Fig. 3-A: Radiograph made after a revision arthroplasty in which fixation of the fracture was attempted with use of the anchoring screws that were employed to fix the acetabular component.

 


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  		Radiograph, made eight months after the arthroplasty, showing non-union of the fracture with failure of the hardware and migration of the component.

 


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  		Radiograph made after repeat revision with supplemental plate-and-screw fixation. The prosthesis was clinically and radiographically well fixed after four years of follow-up.

 
Only two of the ten surviving patients did not have a revision. One (Case 4) had sustained a type-1 fracture of the posterior column as the result of blunt trauma, and the other (Case 5) had sustained a type-1 fracture of the anterior column as the result of a fall. Both fractures were displaced by two millimeters. One fracture had occurred about a component that had been inserted with cement and the other, about a component that had been inserted without cement. The fractures were treated with non-weight-bearing or partial weight-bearing for twelve weeks, followed by progressive weight-bearing as tolerated. Radiographic and clinical union was achieved at six and twenty-four months.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Periprosthetic femoral fractures have been noted increasingly after total hip arthroplasty, perhaps because of the advent of press-fit components designed to be inserted without cement and the increasing frequency with which severe deficiencies of bone are seen in the revision setting1-3,8. The principles of management include non-operative treatment of stable fractures associated with a stable femoral component, open reduction and internal fixation of unstable fractures associated with a stable component, and revision of unstable stems with or without supplemental fixation. Conversely, periprosthetic acetabular fractures have been reported only rarely (McElfresh and Coventry reported only one such fracture after 5400 total hip arthroplasties performed with cement), and the principles of management have not been detailed as extensively.

Miller, in 1972, apparently was the first author to describe ischiopubic fractures in patients who had had a total hip arthroplasty. Nine such fractures were noted, at a mean of twenty-two months postoperatively, about five Ring components that had been inserted without cement and four McKee components that had been inserted with cement. All of the fractures failed to unite after the initial non-operative treatment, and the patients subsequently were managed with removal of the component without reimplantation.

More recently, Silvello et al. reported that loosening of the acetabular component secondary to a fracture was treated successfully with revision of the component and bone-grafting.

Our findings demonstrate that periprosthetic acetabular fractures may occur in association with varying levels of trauma after a total hip arthroplasty. Fractures occurred about acetabular components that had been inserted both with and without cement. While periprosthetic femoral fractures commonly have been associated with loosening of the component and osteolysis1-3,8, only three of our eleven patients had evidence of loosening of the acetabular component (a radiolucent line at the bone-cement interface) before the fracture and none had radiographic evidence of periprosthetic osteolysis (which may contribute to structural failure of the acetabulum) before or immediately after the fracture. A previous revision of the acetabular component could not be conclusively associated with periprosthetic fracture. Four of the eleven fractures in the present study occurred about a component that had been inserted during a revision operation. Over-all, 5220 (22 per cent) of the 23,850 total hip arthroplasties performed at our institution between 1971 and 1991 were revision procedures. Thus, the rate of fracture about revision components in the present study may have been influenced by the prevalence of revision operations at our institution. Major deficiencies of bone, which are observed in many patients who have had a revision arthroplasty, may be associated with an increased risk of fracture with longer follow-up of revision components in general.

Periprosthetic acetabular fractures, like other acetabular fractures, should be evaluated with use of standard radiographs (including oblique Judet radiographs) of the pelvis and possibly plain or computed tomography so that an accurate classification can be made and an appropriate plan of treatment can be developed. The results of periprosthetic acetabular fractures can be catastrophic, as was demonstrated by the death of one of our patients. While previous authors have reported that vascular injury may occur during the insertion of screws for fixation of the acetabular component4, the case of this patient demonstrates that the risk of such an injury may remain throughout the life of the prosthesis. Given this potential for life-threatening intrapelvic vascular trauma, the assessment of hemodynamic stability is an essential part of the initial evaluation, as with any patient who has had major pelvic trauma. Emergency arteriography and operative hemostasis or embolization may be required in some clinical situations.

Our patients were managed both operatively and non-operatively after the fracture. Two patients who had a displaced type-2 fracture (characterized by instability of the acetabular component) were managed with revision arthroplasty immediately after the diagnosis of the fracture. One of these patients subsequently had an additional revision with supplemental plate fixation because of a non-union. Six of the eight type-1 fractures (characterized by apparent stability of the acetabular component) united after non-operative treatment consisting of non-weight-bearing, partial weight-bearing, or modification of activity. However, four of the six patients in whom a type-1 fracture had united ultimately needed revision of the component because of pain and loosening. The fracture itself or the remodeling that occurs after the fracture may result in an altered, incongruous contour of the osseous bed of the component. The fixation and position of the cup and the mechanics of the hip may be compromised, thereby leading to a high rate of revision in this population.

Both of the transverse fractures failed to unite after the initial revision and ultimately were treated with multiple revisions with supplemental internal fixation. In both patients, an attempt to use the cup that was inserted during the initial revision as a so-called internal plate (that is, to achieve both stability of the fracture and fixation of the cup with use of the anchoring screws) failed. While the small size of the present study precludes statistical conclusions, transverse fractures can be quite unstable and may be associated with particularly poor results in this setting. Intensive treatment with supplemental plate fixation of one or both columns to achieve stability of the fracture should be considered. Over-all, eight of the ten patients who survived the fracture had a revision of the component within a mean of fifteen months. Thus, periprosthetic acetabular fractures appear to be associated with a poor prognosis with regard to survival of the component, regardless of the initial treatment.

We cannot provide definitive guidelines for the treatment of these fractures on the basis of the present study because it involved only a small number of patients. However, our current practice involves a careful initial evaluation of the characteristics of the fracture and the stability of the implant with use of multiplane radiographs, tomograms, and a clinical examination. If the implant appears to be stable and well fixed (characteristic of a type-1 fracture), non-operative treatment consisting of non-weight-bearing for six to twelve weeks followed by partial or progressive weight-bearing with close radiographic follow-up may be considered. We do not have experience with the use of traction, a hip-spica cast, or bed rest in the treatment of these fractures. If the implant is unstable (characteristic of a type-2 fracture), an acute revision should be performed after the patient has been medically stabilized. If the fracture appears to be unstable or displaced at the time of the operation, supplemental plate-and-screw fixation with bone-grafting should be performed. The use of a cup inserted with screws as a so-called internal plate does not appear to be a reliable technique for sole fixation of an unstable fracture in this setting.

We conclude that while periprosthetic acetabular fractures are associated with a poor prognosis with regard to the survival of the original acetabular component, some minimally displaced type-1 fractures heal with non-operative treatment without compromising the function of the cup. When the component fails following a fracture, either because of non-union or because of loosening after union has been achieved, salvage is possible by means of revision total hip arthroplasty in a high percentage of patients. However, the component must have structural support by well fixed or healed bone at the time of the operation in order for this procedure to succeed.


   Footnotes
 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

{dagger}Sports Medicine Section, The Hospital for Special Surgery, 535 East 70th Street, New York, N.Y. 10021.

{ddagger}Department of Orthopedics, Mayo Clinic and Mayo Foundation, 200 First Street, S.W., Rochester, Minnesota 55905.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Bethea, J. S., III; DeAndrade, J. R.; Fleming, L. L.; Lindenbaum, S. D.; and |and |Welch, R. B.: Proximal femoral fractures following total hip arthroplasty. Clin. Orthop., 170: 95-106, 1982.

  2. Jensen, J. S.; Barfod, G.; Hansen, D.; Larsen, E.; Linde, F.; Menck, H.; and |and |Olsen, B.: Femoral shaft fracture after hip arthroplasty. Acta Orthop. Scandinavica, 59: 9-13, 1988.[Medline]

  3. Johansson, J. E.; McBroom, R.; Barrington, T. W.; and |and |Hunter, G. A.: Fracture of the ipsilateral femur in patients with total hip replacement. J. Bone and Joint Surg., 63-A: 1435-1448, Dec. 1981.[Abstract/Free Full Text]

  4. Keating, E. M.; Ritter, M. A.; and |and |Faris, P. M.: Structures at risk from medially placed acetabular screws. J. Bone and Joint Surg., 72-A: 509-511, April 1990.[Abstract/Free Full Text]

  5. Letournel, E.: Acetabulum fractures: classification and management. Clin. Orthop., 151: 81-106, 1980.

  6. McElfresh, E. C., and |and |Coventry, M. B.: Femoral and pelvic fractures after total hip arthroplasty. J. Bone and Joint Surg., 56-A: 483-492, April 1974.[Abstract/Free Full Text]

  7. Miller, A. J.: Late fracture of the acetabulum after total hip replacement. J. Bone and Joint Surg., 54-B(1): 600-606, 1972.

  8. Scott, R. D.; Turner, R. H.; Leitzes, S. M.; and |and |Aufranc, O. E.: Femoral fractures in conjunction with total hip replacement. J. Bone and Joint Surg., 57-A: 494-501, June 1975.[Abstract/Free Full Text]

  9. Silvello, L.; Scarponi, R.; Lucia, G.; and |and |Guazzetti, R.: Traumatic loosening of a prosthetic acetabular cup in a young patient. Italian J. Orthop. and Traumatol., 11: 237-239, 1985.[Medline]


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