Intraoperative Fractures of Acetabulum and Proximal Femur in Cementless Primary Total Hip Arthroplasty: A Systematic Review

Sajid Ansari¹, Tushar Gupta¹, Anil Regmi², Arghya Kundu Choudhury¹, Balgovind S Raja³, Roop Bhushan Kalia^4*, Debadatta Panda², Bishwa Bandhu Niraula²

¹Senior Resident, Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
²Junior Resident, Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
³Assistant Professor, Department of Orthopaedics, All India Institute of Medical Sciences, Patna, India
⁴Additional Professor, Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India

*Correspondence author: Roop Bhusan Kalia, MBBS, MS, Additional Professor, Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India; Email: roopkalia2003@yahoo.com

Published Date: 02-08-2023

Copyright© 2023 by Kalia RB, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 

Abstract

Introduction: Cementless Total Hip Arthroplasty (THA) is generally safe, but intraoperative fractures of the acetabulum and proximal femur can occur and can have significant consequences for the patient. This systematic review aims to synthesize the available literature on intraoperative fractures of the acetabulum and proximal femur during primary uncemented THA and highlight the incidence, risk factors, and potential preventive measures for these fractures, to improve patient outcomes and reduce the incidence of this complication.

Methods: We conducted a thorough review in the PUBMED, EMBASE, Cochrane database and Scopus library, and extracted the articles describing the intraoperative acetabulum and femur fractures in primary cementless THA.

Results: The initial search carried out produced 1792 results. After exclusion processing, 22 articles were included for the review. Of these, 16 were intraoperative fractures of the femur and 6 were intraoperative fractures of the acetabulum. Incidence of acetabular fractures was 0.49% and 2.7% for femoral fractures with female preponderance in both groups. Time of occurrence and location of the intra-operative fractures can vary widely, with femoral fractures occurring more commonly during broaching and acetabular fractures during cup implantation.

Conclusion:  A plethora of management options have been utilized according to surgeon preference and the fracture pattern as well as location. Standard principles of fracture fixation and arthroplasty should be followed to achieve stable internal fixation and any unstable fracture site should be bypassed with the utilization of long-stemmed components.

Keywords: Total Hip Arthroplasty; Intra-operative Fracture; Acetabular Fractures; Femur Fractures; Systematic Review

Introduction

Total Hip Arthroplasty (THA) is a commonly performed and most effective and successful orthopaedic procedure in reducing pain, restoring function, and improving a patient’s overall quality of life for the management of hip arthritis [1]. Hence, the demand for primary cementless THA has increased over the past 20 years and is projected to grow exponentially in the upcoming decade [2]. The complications after cementless THA are also expected to concomitantly increase with the increase in procedural volume [2].

The procedure is generally safe, intraoperative fractures of the acetabulum and proximal femur can occur and can have significant consequences for the patient [3]. These fractures can lead to increased morbidity and mortality, prolonged hospital stays and a reduced long-term functional outcome. Most complications associated with THA are uncommon, preventable if anticipated, and managed when recognized [4]. A range of risk factors including smaller incision surgery, uncemented components, prior surgery, female sex, osteoporosis, and inflammatory arthritis have been identified [5]. Femoral intraoperative fractures have been reported to be between 0.1% and 1% for cemented and nearly 5% for cementless primary THA, while periprosthetic acetabular fractures are more uncommon, with reported rates as low as 0.4% [4].

Identifying effective preventive measures can help to reduce the incidence of intraoperative fractures, leading to improved patient outcomes and a reduced burden on the healthcare system [6,7]. This systematic review aims to synthesize the available literature on intraoperative fractures of the acetabulum and proximal femur during primary uncemented THA. The review will identify the incidence, risk factors, and potential preventive measures for these fractures, to improve patient outcomes and reduce the incidence of this complication.

Methodology

Methods

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The initial search was conducted on 01 January 2023 in the electronic databases Pubmed, EMBASE, Cochrane library, and Scopus. The search was conducted using the search term using boolean operators “and” and “or” as “intra-operative fractures” and “acetabulum fracture” OR “femoral fracture” and “primary cementless total hip arthroplasty or “primary uncemented total hip arthroplasty”.

Eligibility Criteria

All original studies were included if (a) Intraoperative fractures of the femur and/or acetabulum during primary cementless total hip arthroplasty were analysed, (b) Sample size of at least 10 cases and (c) Studies in English language. The exclusion criteria included (a) Case series with less than 10 patients, (b) Studies with duplication of data, (c) Case reports, (d) Registry data and (e) Reviews, Letters to the editor, Editorial reviews and Conference posters.

Data Extraction

The authors SA and AR performed the searches and prepared the list based on the inclusion criteria mentioned below. TG, BBN, and DP authors did the data collection and quality assessment using a standardized form. Any disparity between the authors was discussed, and a final consensus was made by the senior author RBK. The reference list of selected articles and various online journals were searched individually for more studies. Data regarding the authors, year of publication, location of study, study design, sample size, follow-up period, preoperative diagnosis, type of index procedure performed, the approach of THA, number of fractures, site, and location of the fracture, method of diagnosis of fracture, an implant used, management of fracture, revisions, radiological and clinical outcomes were extracted.

Quality Assessment

The quality assessment of the studies was conducted using the Methodological Index for Non-Randomized Studies (MINORs) tool. The authors BSR, AKC and DP performed the quality assessment, any disagreements were discussed, and a final consensus was made.

Results

The initial search carried out produced 1792 results after the elimination of duplicates, leaving 1429 studies. Out of 1429 articles 637 were selected for full-text review and resulted in a final pool of 33 studies. A total of 22 articles were finally included in the study as shown in the PRISMA chart (Fig. 1). Of these 16 were intraoperative fractures of the femur and 6 were intraoperative fractures of the acetabulum [3,5-9,11,13,15-17,19-23-28,31].

Patient Characteristics: Six retrospective studies reported intraoperative acetabular fracture during primary total hip arthroplasty on 189 hips [24-28,31]. Haidukewyc, et al., studied 7000 THA with acetabular fractures in 21 hips with an incidence of 0.3% [26]. Hasegawa, et al., studied 406 THA with acetabular fractures in 41 patients with an incidence of 8.4% and Li, et al., reported an incidence of 0.49% (24/4888) [24,28]. Five studies differentiated the sex of patients for intra-operative acetabular fractures on 124 patients with 42 males and 82 females, with a Male: Female ratio of 1:1.95 (Table 1) [24-27,31].

Preoperative Assessment: Four studies mentioned the pre-operative diagnosis for which the patient had undergone THA in 116 intra-operative acetabulum fracture cases [24-27]. Primary osteoarthritis was found in 69 cases (59.48%), followed by 19 AVN cases (16.3%), 10 hips following developmental dysplasia of the hip (8.62%), 7 Non-union neck of femur (6.34%), 6 ankylosing spondylitis (5.17%), 3 RA (2.58%), and 2 post-traumatic arthritis (1.72%) (Table 1).

Procedure and Approach: The Hybrid THA was performed by Haidukewych, et al., in 17/21 cases and Hasegawa, et al., performed only hybrid THA in 41/41 cases of intra-operative acetabulum fracture [24,26]. Rest studies including Haidukewych, et al., performed uncemented THA in 131 cases [26]. Overall, 30.68% (58/189) of intra-operative acetabular fracture cases were operated by the Hybrid technique and 69.31% (131/189) of cases were operated by the uncemented THR technique.

Haidukewych, et al., mentioned 18 anterolateral and three posterolateral approaches [26]. Rest 2 studies by Hasegawa et al. and Li, et al., operated by postero-lateral approaches [24,28]. Overall, the most common approach was the posterolateral / trans-gluteal approach in (62.5%) 90/144 cases, followed by the direct anterior approach in (25%) 36/144 and anterolateral in (12.5%)18/144 hips (Table 2).

Location of Fracture: Five articles mentioned the sites of fracture except Sharkey, et al., four studies were classified according to Hasegawa, et al., classification on 144 patients, where the most common site encountered is the superolateral wall in 26.38% (38/144), followed by other sites outside the acetabulum in 23.61% (34/144) followed by the posterior wall in 18.75% (27/144), anterior wall in 15.9% (23/144), medial wall in 14.58% (21/144) and unclassified in 0.69% (1/144) [27,24]. Laflamme, et al., classified 13 cases according to Judet and Letournel’s classification, anterior wall in 4, medial wall in 7, posterior wall in 9, a posterior column in 6, transverse in 1, and T-type in 1 case (Table 2) [12].

Time of Occurrence and Diagnosis: Dammerer, et al., mentioned that intraoperative fracture was identified in the post-operative phase [29]. Whereas other studies mentioned fracture was identified intra-operatively. Haidukewych, et al., mentioned, in sixteen (76%) of the 21 hips, the fracture was noted during impaction of the real acetabular component in three, it was noted during reaming; and in two, it was noted during initial hip dislocation [26]. Li, et al., reported17 out of 25 fractures during impaction of the real acetabular component, 5 during initial hip dislocation and osteotomy and 1 during reaming [28]. Sharkey, et al., mentioned 13 hips at the time of impaction [27]. Hasegawa, et al., and Laflamme, et al., in (41+32) reported fracture and was diagnosed intra-operatively, but did not actually mention the time of occurrence of fracture [24,25]. Overall, the majority of fractures occurred at the time of impaction.

Hasegawa, et al., used CT scans to diagnose intra-operative acetabular fractures [24]. Laflamme, et al., mentioned that AP and Judet X-rays and CT scans, when available, were used for fracture diagnosis [25]. Haidukewych, et al., mentioned in their study that the fracture was diagnosed clinically [26]. Li, et al., and Sharkey, et al., used fluoroscopy to diagnose fractures (Table 2) [28].

Method of Management and Revision Surgery

Hasegawa, et al., mentioned no additional procedure required for intra-operative fracture management [24]. Haidukewych, et al., replaced the acetabular cup along with supplemental screw fixation in 4 patients with unstable components. No supplemental plates, lag screw or antiprotrusio device was needed in any patients [26]. Li, et al., required two plate fixations and 18 screw fixations, and in 4 patients the fracture was labelled stable and was managed conservatively.[28] Laflamme, et al., required no additional procedure in 16 hips, whereas augmentation with a screw only in 11 hips, and ORIF with posterior plate was required in 5 hips [25]. Sharkey, et al., mentioned screw plus allograft were required in 4 cases, however, other cases required post-operative rehabilitation modification in 2 cases, and no additional intervention was required in 5 hips [27].

Revision surgery was required in 21/189 (11.11%) cases, where Dammerer, et al., mentioned revision surgery in 8 patients (4 for postoperative infection at 2 weeks, 2mo, 10mo, 23mo), 2 for aseptic loosening (at 16mo and 24mo) and cup migration, 2 for protrusion and obvious cup loosening [29]. Haidukewych, et al., mentioned One patient required revision at 2 years [26]. Hasegawa, et al., mentioned 2 cases that had periprosthetic fractures for which a dome screw fixation with both a peripheral self-locking cup and a hemispheric cup was used respectively [24]. Laflamme, et al., mentioned revision surgery was required in 8 hips and Sharkey, et al., mentioned in 2 cases but the details of revision surgery performed was not elaborated in their study (Table 3) [25].

Clinico-Radiological Outcome

Haidukewych, et al., mentioned assessing pain, walking ability, and the need for walking aids, where out of eighteen patients, fifteen had no pain and three had mild trochanteric discomfort [26]. Only two required walking aids; in both cases, walking aids were required to be a cause of chronic spine problems and not because of problems related to the hip. Li, et al., mentioned 22/24 of hip cases walked independently without any support [28]. Overall, the score was excellent in 12 patients and good in 10 patients, where Harris Hip Score was increased from mean pre-op HSS of 30.8± 9.7, to mean postop HSS of 90.2±4.2. Sharkey, et al., mentioned 4/13 complained of groin pain (2 had fractures identified intraoperatively and 2 were identified in the postoperative period), 1 died in the early postoperative period due to unrelated causes, and 1 had the postoperative infection for which resection arthroplasty was performed [27]. Three studies did not discuss the clinical outcome at the final follow-up [24,25,31]. Haidukewych, et al., mentioned that all fractures were united and all fractures had evidence of osseous ingrowth without component migration, 1 case had a well-fixed acetabular component for which he underwent revision [26]. Hasegawa, et al., mentioned bony ingrowth fixation in all cases [24]. Li, et al., mentioned excellent radiological outcomes with no loosening, osteolysis or migration of acetabular and femoral components and fractures were united in all cases as evidenced by X-rays [28]. Sharkey, et al., mentioned that there was radiographic evidence of healing in 10 patients (Table 3) [27].

Rehabilitation Protocol

Three studies discussed the modification in post-operative rehabilitation protocol [24,27,28]. Hasegawa, et al., mentioned that patients with occult fractures were kept on toe touch weight-bearing exercises for 6-8 and 2 patients with periprosthetic acetabular fractures were kept for non-weight bearing for 3 weeks [24]. Li, et al., mentioned that 5 patients avoided weight bearing for 4 weeks, and rest weight bearing as tolerated after surgery [28]. Sharkey, et al., mentioned that 10% weight-bearing for patients when the fracture was identified intraoperatively and in two patients non-weight bearing mobilization for 6 and 8 weeks was advised (Table 3) [27].

Femur Fractures

Patient Characteristics: Among the studies reporting intraoperative femur fracture during primary total hip arthroplasty [3,5-9,11,13,15-17,19-23]. One was a prospective study and the rest were retrospective studies [14]. Overall, the total number of intra-operative femur fracture was 595. The total number of patients enrolled in 16 studies was 21423, out of which 595 had femur fractures, with an overall incidence of 2.7%. 13 studies differentiate the sex of the study population, on 5259 patients of 16 studies. But only four studies mentioned the sex of patients in terms of intra-operative femur fracture where out of 195 patients, 79 were male and the rest were female, with Male: Female ratio of 1:1.46. Five studies mentioned the follow-up duration with a mean follow-up of 43 months (12-90 months) (Table 4) [5,7,11,15,16,21,23].

Preoperative Assessment

11 studies mentioned the pre-operative diagnosis for which the patient had undergone THR on 6202 hips [6-9,13,15-17,20-23]. Osteoarthritis was the cause of THR in 62.67% (n=3894), Developmental dysplasia of the hip in 17.76% (n=1102), Avascular necrosis of the femoral head in 13.09% (n=812) and post-traumatic arthritis in 6.35% (n=394) (Table 4).

Procedure and Approach

13 studies mentioned the type of procedure performed on 18025 hips with 687 fractures that had undergone the Uncemented THR. Rest six studies didn’t mention the type of THR done. The approach used was mentioned by 10 studies where, anterolateral approach was performed in 11.54% (n=86) fracture cases, the direct anterior approach in 36.1% (n=269) fracture cases, the direct lateral in 32.21% (n=240 cases), and posterolateral in 42.5% (n=317) fracture cases (Table 5).

Location of Fracture

Three studies classified according to Mallory classification on 113 fracture cases, where Mallory type 1 was found in 68.14% (n=77) cases, and 11.5% (n=13) fractures were type II, 4.42% (n= 5) fractures type III and 15.92% (n=18) type IV fractures (Table 5) [9,13,14].

Time of Occurrence and Diagnosis

14 studies mentioned intraoperative fractures at 88.41% (n=618), and 2 studies mentioned that the fractures were diagnosed in immediate post-operative periods in 17 patients [3,5-7-9,11,13,15-17,19-21-23]. Regarding the diagnosis of fractures, 21.26% (n=171) fractures were diagnosed clinically, whereas 64.80% (n=521) fractures were diagnosed radiographically and 13.93% (n=112) fractures were diagnosed by CT scan (Table 5).

Method of Management and Revision Surgery

Only 12 studies discussed the management of fractures where encirclage with Cerclage wire/band was done in 57.24% (n=316) fractures, revision surgery was performed in 2.89% (n=16), Bone graft was done in 0.3% (n=2), Circlage wire with long stem was done in 0.5% (n=3), non-operatively managed in 1.08% (n=6), and the treatment method was not discussed in 22.46% (n=124) fractures. Overall, the most common method of management done was encircling with cerclage wire or band.

A total of 5 studies mentioned revision surgeries in the post-operative period. Haidukewych, et al., mentioned one patient required revision [26]. Cohen, et al., mentioned just two patients (0.4%) in this series where the IFF changed management, requiring a revision femoral stem [16]. Miettinen, et al., mentioned 12 underwent revision surgeries [21]. Tamaki, et al., mentioned that stem revisions were noted after the use of a stem with a short tapered-wedge design that was inserted through the direct anterior approach (Table 6) [8].

Clinico-Radiological Outcome

Berend, et al., found that HHS improved an average of 34 points [9]. Ferbert, et al., mentioned mean improvement in HHS was 35.3 [13]. Overall, there was an increase in HHS by 39.43 in the post-operative phase (Table 6).

Rehabilitation Protocol

Ferbert, et al., mentioned that Postoperative rehabilitation was started on the first day after surgery [13]. Full weight-bearing and both active and passive motion exercises of the involved joint were allowed on the first postoperative day. Miettinen, et al., mentioned that partial weight bearing was started in cases with intra-operative fractures which were not fixed with cable wires [21]. Timmer, et al., mentioned that patients with intra-operative fractures were treated with a weight-bearing restriction for 6 weeks, followed by limited weight-bearing the first 6 weeks after surgery [11]. The rest of the studies suggested the normal post-operative rehabilitation protocol with full weight bearing if the fracture was fixed intra-operatively and to manage with a non-weight bearing if the fracture was not fixed intra-operatively (Table 6).

Quality Assessment

The studies included in this review varied considerably with MINORS scores. Since all included studies are non-comparative study, the total score is of 16, the calculated score ranged from 7 to 13. The study had a score of 10 or more is considered as good quality, and includes 10 such articles, the rest of the papers have a score of less than 10 (Table 7).

Figure 1: PRISMA Chart.

Table 1: Acetabular fracture, patient demographics including preoperative diagnosis and follow up.

Table 2: Acetabular fracture, characteristics of fracture and intra operative details.

Table 3: Acetabular fracture, post op outcome.

Table 4: Femur fracture, patient demographics.

Table 5: Femur fracture, characteristics of fracture and intra operative details.

Table 6: Femur fracture, post op outcome.

Table 7: MINORs scoring.

Discussion

Intra-operative periprosthetic fracture during primary total hip arthroplasty is a relatively common entity with the femoral side being involved more than the acetabular side and there are some studies existing in literature on this topic [32]. We conducted a systematic review of the available literature to define the incidence, risk factors, time of occurrence of the fracture during surgery, characteristics of the fractures, management options and outcomes. We have also identified precautions to be taken to prevent these fractures. No study in literature has defined the amount of impacting force as a determinant to the occurrence of intraoperative fracture. However, from our common shared experience we know that hammering the trial or final acetabular component of a smaller size than the rim fit may lead to acetabular fracture. Similarly, the femoral fractures occur when the trial of larger size is hammered into a smaller canal.

Acetabular Fractures

We identified incidences ranging from 0.3% to 8.4% but this may be underestimated as some of the intraoperative fractures may go unnoticed, and minimally displaced fractures not requiring any intervention may not be reported. The majority of the authors in this review reported incidence below 1% [25-28,31]. An overall incidence of 0.49% was noted (86/12294) in patients with a mean age of 61.46 years at a mean follow-up of 32.4 months (12-58 months). Two studies performed hybrid THR in the majority (58/62) of such patients however overall, 69.31% (131/189) of cases were operated by the uncemented THR technique. The maximum number of such cases were being operated through the posterolateral / trans-gluteal approaches and the minimum cases by the anterolateral approach. However, it remains the surgeon’s preference to pursue these approaches and the intraoperative fracture was not related to the approach used.

Hasegawa, et al., classification was used most commonly to classify the location of the fracture and the most common site encountered was the superolateral wall (26.38%) whilst the medial wall was noted to be the least common site [24]. Most studies described that these fractures can and must be picked intraoperatively. However, it was virtually impossible to diagnose the exact timing of the fracture and invariably the fracture was noted at the time of impaction of the final acetabular component. It is worth noting that one must be suspicious about the occurrence of such fractures and must rule them out using X-rays and CT scans wherever available apart from clinically.

The management of these fractures depends on the stability of the final acetabular component. A well-fixed and stable component warrants no further intraoperative intervention. However, some authors have suggested additional screws or replacing the component allowing supplemental screw fixation. Sharkey, et al., has also suggested the use of screw plus allograft as a supplement to fixation [27]. Two authors have suggested plate fixation in certain cases [26,30]. However, no use of an antiprotrusio device was found necessary by any of the authors. Post-operative rehabilitation protocol is modified in all such cases as a norm.

Revisions needed to be performed in 11.11% of cases. However, these revisions were attributable to causes not modified by the intraoperative fractures such as postoperative infection, aseptic loosening, cup migration, protrusion/ obvious cup loosening and periprosthetic fractures.

The final clinical outcomes were described by three studies. 38/42 hip cases walked independently without any support. Two patients had to use walking aids owing to chronic spine etiologies. Harris Hip Score was found to improve from mean pre-op HSS of 30.8± 9.7 to mean postop HSS of 90.2±4.2.

The final radiological outcomes were described by five studies. It is noteworthy that all the authors independently concluded that all the fractures had radiological evidence of osseous ingrowth and fixation in all cases. The rehabilitation protocol should be modified keeping in mind the healing of the fracture. Non-weight bearing for 3-4 weeks followed by toe touch or weight bearing as tolerated in occult or obvious fractures respectively.

Femur Fractures

595 intraoperative fractures were noted in 16 studies [3,5-9,11,13,15-17,19-23]. Total patients were documented as 21423 across 16 studies in which the incidence was seen to be 2.7%. Four studies found that the incidence of male: female was 1:1.46. Mean follow-up was found to be 43 months (12-90 months) in seven studies. The pre-operative diagnosis was found to be osteoarthritis most commonly in 62.67%, DDH hip in 17.76%, AVN hip in 13.09% and post-traumatic arthritis in 6.35%.

Procedure and Approach

687 fractures were noted in 23025 hips in 18 studies accounting for uncemented THR. Femoral fractures were noted most commonly in posterolateral approach followed by direct anterior and direct lateral approach.

Fracture Location

Three studies documented the location as per the Mallory classification where type I was found most commonly and type II was found least commonly.

Time of Occurrence and Diagnosis

The majority of the fractures were diagnosed intraoperatively (88.4%) whilst the rest were diagnosed postoperatively (11.5%). Diagnosis in most cases was radiographic (64.8%) while the rest of the cases were diagnosed clinically or by CT scan.

Method of Management and Revision Surgery

12 studies discussed the management of these fractures ranging from nonoperative management to revision surgery including encircling with cerclage wire/band which was the most common method of management (57.2%) to bone grafting and cerclage wire with replacement with a long stem [8,9,11-13,16,17,19,21-23]. Management was not mentioned in 22.46% of these studies suggesting that management techniques may vary beyond the ones mentioned and may be devised on the table as per the fracture timing, location, pattern and availability of implants.

Revision surgeries were needed in very few cases and out of these cases short tapered-wedge design that was inserted through the direct anterior approach was commonly found.

Clinico-Radiological Outcome

Outcomes were recorded in terms of Harris Hip score and were found to improve from 34 points to 49 points in various studies. The mean improvement was found to be 39.43 in the postoperative period.

Rehabilitation Protocol

It is noteworthy that the studies conclude a full weight-bearing mobilization be allowed in cases where satisfactory intraoperative fixation has been achieved and a non-weight-bearing protocol be followed for 6 weeks in patients where an intraoperative fixation has not been achieved.

The current review to the best of our knowledge is only the review to assess intra-operative acetabulum and proximal femur fracture in total hip arthroplasty encompassing a wide variety of studies with a representative cumulative sample. But this study has its limitations, first longer follow up studies are required for actual assessment of the outcome. Secondly only one study included was prospective study, majority of the articles are retrospective, thirdly there were no comparative study exists where compares conservative management or augmentation method and also in augmentation method there is no comparative study on the available method of augmentation. Lastly, the protocol for the review was not pre-registered for systematic review.

Conclusion

Intra-operative fractures during primary total hip arthroplasty are not very rare with higher risk associated with factors contributing to poor bone quality such as osteoporosis, rheumatoid arthritis, advanced age, female gender, chronic steroid use, metabolic bone disorders etc. Patients with such risk factors warrant careful pre-operative planning with a full medical history, evaluation of bone stock and maintaining inventory of appropriate instruments and implants. The inaccurate technique of exposure, bone preparation and trialing, final femoral implant placement, reaming of the acetabulum and impaction of the acetabular component are associated with a higher incidence of these fractures. A plethora of management options has been utilized according to surgeon preference and the fracture pattern as well as location. Standard principles of fracture fixation and arthroplasty should be followed to achieve stable internal fixation and any unstable fracture site should be bypassed with the utilization of long-stemmed components. A satisfactory radiographic and functional outcome can be expected with appropriate treatment.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Contributions

SA: Planning of study, data management, writing and revising the manuscript; TG: Planning of study, data management; AR: Planning of study, writing and revising the manuscript; BBN: Data management, manuscript preparation; DP: Data management, manuscript preparation; AKC: Planning of study, revising the manuscript; BSR: Planning of study, revising the manuscript; RBK: Planning of study, writing and revising the manuscript.

Ethical Approval:

This study was performed in line with the principles of the Declaration of Helsinki. The intuitional ethical committee has provision that ethical clearance is not required for review articles and for paper publication for the same.

References

1. Pronk Y, van der Weegen W, Schreurs BW, Pilot P. Quality of total hip arthroplasty health care based on four years of patient-reported outcomes in the Netherlands. Health Qual Life Outcomes. 2023;21:24.
2. Shichman I, Roof M, Askew N, Nherera L, Rozell JC, Seyler TM, et al. Projections and epidemiology of primary hip and knee arthroplasty in medicare patients to 2040-2060. JBJS Open Access. 2023;8:e22.00112.
3. Liu B, Liu S, Wu T, Liu Z, Chen X, Li M, et al. Risk factors for intraoperative periprosthetic femoral fractures in patients with hip dysplasia undergoing total hip arthroplasty with uncemented prostheses. Orthop Surg. 2021;13:1870-81.
4. Siddiqi A, Springer BD, Chen AF, Piuzzi NS. Diagnosis and management of intraoperative fractures in primary total hip arthroplasty. JAAOS – J Am Acad Orthop Surg. 2021;29:e497.
5. Berend KR, Lombardi AV. Intraoperative femur fracture is associated with stem and instrument design in primary total hip arthroplasty. Clin Orthop Relat Res. 2010;468:2377-81.
6. Zhao R, Cai H, Liu Y, Tian H, Zhang K, Liu Z. Risk factors for intraoperative proximal femoral fracture during primary cementless THA. Orthopedics. 2017;40:e281-7.
7. Rüdiger HA, Betz M, Zingg PO, McManus J, Dora CF. Outcome after proximal femoral fractures during primary total hip replacement by the direct anterior approach. Arch Orthop Trauma Surg. 2013;133:569-73.
8. Tamaki T, Jonishi K, Miura Y, Oinuma K, Shiratsuchi H. Cementless tapered-wedge stem length affects the risk of periprosthetic femoral fractures in direct anterior total hip arthroplasty. J Arthroplasty. 2018;33:805-9.
9. Berend KR, Lombardi AV, Mallory TH, Chonko DJ, Dodds KL, Adams JB. Cerclage wires or cables for the management of intraoperative fracture associated with a cementless, tapered femoral prosthesis: Results at 2 to 16 Years. J Arthroplasty. 2004;19:17-21.
10. Hendel D, Yasin M, Garti A, Weisbort M, Beloosesky Y. Fracture of the greater trochanter during hip replacement. Acta Orthop Scand. 2002;73:295-7.
11. Timmer C, Gerhardt DMJM, De Visser E, de Kleuver M, Van Susante JLC. High incidence of intraoperative calcar fractures with the cementless CLS Spotorno stem. Eur J Orthop Surg Traumatol. 2018;28:1291-6.
12. Mont MA, Maar DC, Krackow KA, Hungerford DS. Hoop-stress fractures of the proximal femur during hip arthroplasty. Management and results in 19 cases. J Bone Joint Surg Br. 1992;74-B:257-60.
13. Ferbert T, Jaber A, Gress N, Schmidmaier G, Gotterbarm T, Merle C. Impact of intraoperative femoral fractures in primary hip arthroplasty: a comparative study with a mid-term follow-up. HIP Int. 2020;30:544-51.
14. Bonnin MP, Neto CC, Aitsiselmi T, Murphy CG, Bossard N, Roche S. Increased incidence of femoral fractures in small femurs and women undergoing uncemented total hip arthroplasty – why? Bone Jt J. 2015;97-B:741-8.
15. Tootsi K, Lees L, Geiko B, Märtson A. Intraoperative complications in total hip arthroplasty using a new cementless femoral implant (SP-CL^®). J Orthop Traumatol. 2020;21:8.
16. Cohen EM, Vaughn JJ, Ritterman SA, Eisenson DL, Rubin LE. Intraoperative femur fracture risk during primary direct anterior approach cementless total hip arthroplasty with and without a fracture table. J Arthroplasty. 2017;32:2847-51.
17. Ponzio DY, Shahi A, Park AG, Purtill JJ. Intraoperative proximal femoral fracture in primary cementless total hip arthroplasty. J Arthroplasty. 2015;30:1418-22.
18. Li J, Ji Q, Ni M, Zheng Q, Sun J, Zhang G. Management of intraoperative acetabular fracture in primary total hip arthroplasty. BMC Musculoskelet Disord. 2020;21:383.
19. Fleischman AN, Schubert MM, Restrepo C, Chen AF, Rothman RH. Reduced incidence of intraoperative femur fracture with a second-generation tapered wedge stem. J Arthroplasty. 2017;32:3457-61.
20. Sun G, Yin Y, Ye Y, Li Q. Risk factors for femoral fracture in lateral decubitus direct anterior approach total hip arthroplasty using conventional stems: a retrospective analysis. J Orthop Surg. 2021;16:98.
21. Miettinen SSA, Mäkinen TJ, Kostensalo I, Mäkelä K, Huhtala H, Kettunen JS, et al. Risk factors for intraoperative calcar fracture in cementless total hip arthroplasty. Acta Orthop. 2016;87:113-9.
22. Hartford JM, Knowles SB. Risk factors for perioperative femoral fractures: cementless femoral implants and the direct anterior approach using a fracture table. J Arthroplasty. 2016;31:2013-8.
23. Colacchio ND, Robbins CE, Aghazadeh MS, Talmo CT, Bono JV. Total hip intraoperative femur fracture: do the design enhancements of a second-generation tapered-wedge stem reduce the incidence? J Arthroplasty. 2017;32:3163-8.
24. Hasegawa K, Kabata T, Kajino Y, Inoue D, Tsuchiya H. Periprosthetic occult fractures of the acetabulum occur frequently during primary THA. Clin Orthop Relat Res. 2017;475:484-94.
25. Laflamme G-Y, Belzile EL, Fernandes JC, Vendittoli PA, Hébert-Davies J. periprosthetic fractures of the acetabulum during cup insertion: posterior column stability is crucial. J Arthroplasty. 2015;30:265-9.
26. Haidukewych GJ, Jacofsky DJ, Hanssen AD, Lewallen DG. Intraoperative fractures of the acetabulum during primary total hip arthroplasty. JBJS. 2006;88:1952.
27. Sharkey PF, Hozack WJ, Callaghan JJ, Kim YS, Berry DJ, Hanssen AD, et al. Acetabular fracture associated with cementless acetabular component insertion: A report of 13 cases. J Arthroplasty. 1999;14:426-31.
28. Li J, Ji Q, Ni M, Zheng Q, Sun J, Zhang G. Management of intraoperative acetabular fracture in primary total hip arthroplasty. BMC Musculoskelet Disord. 2020;21:383.
29. Dammerer D, Putzer D, Glodny B, Petersen J, Arrich F, Krismer M, et al. Occult intra-operative periprosthetic fractures of the acetabulum may affect implant survival. Int Orthop. 2019;43:1583-90.
30. Tootsi K, Lees L, Geiko B, Märtson A. Intraoperative complications in total hip arthroplasty using a new cementless femoral implant (SP-CL®). J Orthop Traumatol. 2020;21:8.
31. Yamamuro Y, Kabata T, Kajino Y, Inoue D, Hasegawa K, Tsuchiya H. Does intraoperative periprosthetic occult fracture of the acetabulum affect clinical outcomes after primary total hip arthroplasty? Arch Orthop Trauma Surg. 2022;142:3497-504.
32. Tsiridis E, Haddad FS, Gie GA. The management of periprosthetic femoral fractures around hip replacements. Injury. 2003;34:95-105.