Periprosthetic Fracture, ABOS Oral Boards Preparation

This is a 72-year-old woman who fell from standing at home. She had a left cemented total hip arthroplasty eight years ago for osteoarthritis, and prior to this fall she was ambulatory without assistive devices with an excellent result, no pain, no limp. She presented with acute left thigh pain and inability to bear weight. On exam, the left thigh was swollen and tender in the mid-diaphyseal region. There was no deformity at the hip. Her prior posterolateral incision was well-healed with no signs of infection. Distal neurovascular exam was intact.

AP and lateral radiographs showed a spiral fracture of the femoral shaft at the tip of the cemented femoral stem. I compared these to her post-operative films from six years ago, the stem had no subsidence and there were no lucent lines around the cement mantle, suggesting the stem was well-fixed. The fracture extended approximately 2 centimeters distal to the stem tip. The acetabular component was well-positioned without loosening.

This is a Vancouver B1 periprosthetic fracture, a fracture around a well-fixed stem.

I performed ORIF through a lateral approach with a locking plate, cerclage cables proximally, and cortical strut allograft augmentation. Intraoperatively, I confirmed the stem was solidly fixed.

Post-operatively, she was made toe-touch weight-bearing for twelve weeks to protect the fixation. At six weeks, she was comfortable and X-rays showed maintained alignment with early callus. At three months, there was progressive healing and she advanced to full weight-bearing. At six months, the fracture was healed, the stem remained well-fixed, and she was back to ambulating without assistive devices.

She was satisfied with her recovery and the implant was preserved. If I were to treat this case again, I would consider using a longer plate with more distal fixation points. The construct worked, but the distal working length was on the shorter end of what I would have liked, and a longer plate would have provided a more generous stress riser transition. I monitored for signs of stem loosening and infection throughout the follow-up period, and both the fracture fixation and the arthroplasty remained stable.