Periprosthetic fractures in the resurfaced hip—A case report and review of the
Stephen A. Brennan*, Brian M. Devitt, Cathleen J. O’Neill, Paul Nicholson
Adelaide and Meath Hospital, Dublin, Ireland
The femoral neck fracture rate in the first year following hip
resurfacing has been reported as 1.31%.1There are both patient and
surgeon controlled factors which contribute to the risk of fracture.
Female gender, a high body mass index and osteoporosis have all
been associated with an increased risk.2Surgical factors such as
femoral neck notching and a malpositioned femoral component
may also contribute to this mode of failure.3,4
There is a naturally occurring rate of femoral neck fracture in a
population regardless of whether or not they have had resurfacing
surgery. As this young active population ages, we are likely to
encounter a rise in periprosthetic fractures adjacent resurfacing
implants. When secondary to avascular necrosis the usual
treatment is conversion to a stemmed femoral component. In
the setting of trauma however both non-operative and operative
treatment options exist. This paper reports a periprosthetic
fracture in a resurfaced hip successfully treated with cannulated
screw fixation and reviews the current literature.
A healthy 69-year old male with end stage osteoarthritis of his
right hip underwent Birmingham (Smith & Nephew, Memphis,
Tenn) Hip Resurfacing through an anterolateral approach. His post-
operative course was uneventful and at six-month follow up he
was pain free and had returned to full activity. One year following
his index procedure he fell from a standing height sustaining a
basal cervical periprosthetic fracture (Figs. 1–4).
The fracture was reduced closed under traction. Two 6.5 mm
Richards cannulated screws (Smith & Nephew, Memphis, Tenn)
were placed into the superior neck under image guidance. The
patients surgery took place less than twelve hours after injury. The
patient was discharged home on the second post-operative day on
crutches touch toe weight bearing for six weeks. At two years
follow up the patient was asymptomatic and had returned to
distance running. His Harris Hip score was 98. Radiologically the
fracture was united with remodeling evident.
When a traumatic periprosthetic fracture is encountered the
surgeon must decide whether to retain a previously well
functioning prosthesis or convert to a stemmed total hip
replacement. There a number of case reports supporting a
conservative treatment strategy for un-displaced neck of femur
fractures.5–7Non operative treatment involves a prolonged period
of immobility. This has the associated risks of deep venous
thrombosis and lower respiratory tract infection. In addition, this
method of treatment may lead to loss of muscle mass and prolong
pain during healing.
When considering surgical fixation the main obstacle encoun-
tered is adequate proximal fragment purchase, whilst avoiding the
femoral stem and not disrupting the cement mantle. The target
area between the stem and the inner surface of the femoral
component in a 50 mm Birmingham implant is 17.2 mm. This is
large enough to easily accommodate the threads of a 6.5 mm
Richards screw. Placement of a 12.7 mm Compression Hip Screw
(Smith and Nephew, Memphis, Tenn) and side plate construct
would be technically challenging and risk disruption of the cement
mantle. Other technical considerations include an acceptable
reduction so as to avoid edge loading and adverse wear.
Injury, Int. J. Care Injured 44 (2013) 263–265
A R T I C L E
I N F O
Accepted 4 September 2012
A B S T R A C T
Traumatic periprosthetic fractures adjacent a hip resurfacing prosthesis are rare. When proximal
fractures are encountered the obvious surgical solution is to revise to a large head stemmed femoral
component. A previously well functioning implant may however be retained as various non-operative
and operative treatment options exist. This paper reports the case history of a traumatic periprosthetic
fracture successfully treated with cannulated screw fixation and reviews the current literature.
? 2012 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +353 01 4142000; fax: +353 091 526588.
E-mail address: email@example.com (S.A. Brennan).
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0020–1383/$ – see front matter ? 2012 Elsevier Ltd. All rights reserved.
Cannulated screws have been used successfully to treat
mid-cervical, basi-cervical and inter-trochanteric neck of femur
fractures (Table 1).8–10If the fracture is intra-capsular and grossly
displaced however this method should be avoided because
avascular necrosis of the head remnant may result in early
Inter-trochanteric fractures have also been managed success-
fully with a blade plate, reversed distal femoral locking plates and
proximal femoral locking plates.12–15These methods of fixation
require extensive dissection with increased resultant blood loss
when compared to cannulated screws. In addition to this the
insertion of a blade plate adjacent a resurfacing is technically
demanding and there is potentially reduced hold on the proximal
Sub-trochanteric fractures have been treated using a recon-
struction nail, contoured AO DCP and more recently trochanteric
entry point cephallo-medullary nails.16–18The DCP is an attractive
option if an intramedullary nail is likely to cause further
comminution, achieve inadequate fixation in the femoral neck
or if the fixed angulation of the locking screws within the nail is
Fig. 1. Antero-posterior view radiograph showing periprosthetic fracture.
Fig. 2. Lateral radiograph showing periprosthetic fracture.
Fig. 3. Post-operative antero-posterior radiograph.
Fig. 4. Post-operative lateral radiograph.
Summary of publications.
No. of cases
Undisplaced neck of femur
(b)Reverse oblique per-trochanteric
Distal femoral locking plate
Distal femoral locking plate
AO Lag screws
Proximal femoral locking plate
S.A. Brennan et al. / Injury, Int. J. Care Injured 44 (2013) 263–265
precluded by the stem of the resurfacing arthroplasty. An intra- Download full-text
medullary nail is however biomechanically favourable to a plate
and is a load sharing construct. In addition to this it can be inserted
in a minimally invasive manner with little blood loss.
Revising the hip to a long stemmed femoral component negates
the benefits of conservation of femoral bone stock in the young
patient and involves removing an otherwise well aligned and fixed
implant. Traumatic femoral neck fractures involving hip resurfa-
cing prostheses may be treated surgically without revision with a
good functional outcome.
Conflict of interest statement
The authors declare that they have no conflict of interest.
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