Fracture After Hip Replacement Surgery
What Is a Periprosthetic Fracture?
A periprosthetic fracture is a break in the bone around or near an orthopaedic implant. This page covers periprosthetic fractures that develop after a total hip replacement, around the femur (thigh bone) and, less commonly, the acetabulum. It is uncommon but is a serious complication that usually requires surgery.
A fracture can also occur during surgery; but most occur years after the replacement, following a fall. Patients are often older with lower bone quality and accompanying illnesses, which can make treatment more challenging. For other hip problems you can review the hip page.
How Does It Happen? Risk Factors
Fractures around an implant most often occur after a fall; blows to the side of the hip and high-energy trauma such as road-traffic accidents can also cause them. The strength of the bone and the state of the implant determine whether a fracture occurs.
- Conditions that raise the risk of falling: muscle weakness, balance and vision problems, and medications that cause dizziness.
- Conditions that weaken bone: osteoporosis and bone loss around the implant (osteolysis).
- Loosening of the implant stem over time; this both predisposes to a fracture and affects treatment.
- Conditions that disrupt the bone-implant integrity, such as a joint prosthesis infection.
Location and Classification of the Fracture
Most periprosthetic fractures occur around the implant stem placed in the femur; fractures around the acetabulum are rarer. The three most important questions in the treatment decision are the location of the fracture relative to the stem, whether the implant stem is well fixed or loose, and the quality of the surrounding bone.
These three factors determine whether the fracture needs only fixation or whether the implant also needs to be changed. For this reason both the fracture and the existing implant are assessed in detail on imaging.
The Vancouver classification is widely used to describe periprosthetic femoral fractures. This system groups the fracture roughly by its location relative to the tip of the stem, whether the stem is well fixed or loose, and the surrounding bone stock. Its aim is to provide a comparable language and a consistent treatment plan for the same group of patients.
Symptoms
Fractures around an implant usually cause obvious and severe symptoms; in most cases the diagnosis is apparent at the moment of injury.
- Sudden, severe pain in the hip or thigh and an inability to bear weight on the leg.
- Swelling and bruising in the area.
- Shortening, angulation or deformity of the leg.
- In some cases with a loose implant, ongoing thigh pain and a worsening gait before the fracture.
Emergency Assessment and Diagnosis
Because these fractures are very painful, patients usually go to the emergency department. The assessment is not limited to the bone; the patient is treated as a whole, the reason for the fall is looked into and the blood supply and nerves of the leg are checked.
An X-ray assesses the pelvis, hip and thigh and shows the relationship of the fracture to the implant; CT provides a three-dimensional assessment where needed. If loosening of the implant or an infection is suspected along with the fracture, these are investigated with additional tests. General health is assessed before surgery.
Surgical Treatment Options
The large majority of periprosthetic hip fractures require surgery. The method is chosen according to the location of the fracture, the quality of the bone and, most importantly, whether the implant stem is well fixed or loose.
- Open reduction and internal fixation: if the stem is well fixed and stable, the bone fragments are fixed with a plate, screws and cables, supported with a bone graft where needed.
- Revision arthroplasty: if the stem is loose, the existing implant is removed and usually a new, longer-stemmed prosthesis is placed; weak areas of bone can be supported with a graft.
- Combined approach: in some cases both fracture fixation and revision of the implant are done together.
Recovery and Rehabilitation
Recovery time varies with the type of fracture, the surgery performed and the patient's bone quality. Permission for weight-bearing and its timing are set gradually according to the fixation of the fracture and the state of the implant, following the doctor's plan.
Physiotherapy begins early and aims to restore safe walking, muscle strength and balance. Protection against clots related to immobility is also part of the plan; the deep vein thrombosis page gives general information on this.
Prevention
In patients with a prosthesis, a proportion of periprosthetic fractures can be prevented by reducing the risk of falls and bone weakness. Regular follow-up helps to catch problems such as loosening and bone loss early.
- Reducing fall hazards at home, wearing suitable footwear and using a cane where needed.
- Preserving bone health: screening for and treating osteoporosis, adequate calcium and vitamin D.
- Regular exercise that improves muscle strength and balance and regular checks of the prosthesis.
When Should You See a Doctor?
In a hip with a prosthesis some symptoms are an emergency and some call for early assessment.
- After a fall there is severe hip or thigh pain, an inability to bear weight or a short, deformed leg; go to the emergency department immediately.
- Even without a fracture, if there is steadily increasing thigh pain or a worsening gait in a hip with a prosthesis, have it assessed for loosening.
- Symptoms such as fever, wound drainage or one-sided calf swelling should be assessed for infection or a clot.
For the assessment of fractures and complications after a replacement you can contact Assoc. Prof. Serkan Sürücü, and you can also review the other conditions covered within hip surgery.