EPIDEMIOLOGY: Hip and Knee

doi:10.1016/S0030-5898(05)70073-0

Orthopedic Clinics of North America

Volume 30, Issue 2, 1 April 1999, Pages 183-190

https://doi.org/10.1016/S0030-5898(05)70073-0 Get rights and content

Intraoperative and postoperative periprosthetic fractures appear to be increasing in number.20, 32, 56 Intraoperative fractures have become more common with the advent of uncemented press-fit implants.²⁰ Postoperative fractures have also become more common as the population of at-risk patients with joint arthroplasty has increased.²⁰ The number of patients living with hip and knee arthroplasties has risen considerably over the last two decades, and after several decades of joint arthroplasty, the number of patients with multiply revised joints, bone loss, and osteolysis has also risen.

This article reviews the epidemiologic features of periprosthetic fractures around total hip arthroplasty and total knee arthroplasty according to the site of fracture occurrence. The frequency and cause of intraoperative and postoperative periprosthetic fractures vary by anatomic site. For each anatomic site, unique risk factors, some demographic and some technical, appear to be related to risk of fracture. For several anatomic sites, excellent articles that collate large numbers of series are available to the reader and provide aggregate information concerning the epidemiology of these fractures.13, 29, 31, 37, 53, 56 From a broad perspective, there is little information in the literature on the relative frequency of periprosthetic fractures at each anatomic site. To provide some perspective, this article also makes use of previously unpublished data from the Mayo Clinic total joint registry.*

Section snippets

Intraoperative

Intraoperative periprosthetic acetabular fractures are a phenomenon ascribable to use of press-fit uncemented acetabular components. The fractures vary in severity from minor cracks involving only the rim of the socket to major disruptions of the pelvis. The overall incidence of the problem is unknown.⁸ The only series reported to date included only 13 fractures gathered from three institutions, suggesting that major intraoperative acetabular fractures are uncommon. Women predominated in that

PERIPROSTHETIC FRACTURES AROUND TOTAL KNEE ARTHROPLASTY

As is the case for total hip arthroplasty, figures for the rate of periprosthetic fractures around total knee arthroplasty are difficult to obtain from the literature because such figures depend on many factors, including (1) length of follow-up time, (2) demographic makeup of the patient population, (3) total knee arthroplasty design, (4) techniques of insertion, and (5) whether the patella was resurfaced. To date, the author is aware of no studies that have reviewed the overall rate of

PERIPROSTHETIC TIBIA FRACTURES

Little has been written about periprosthetic tibial fractures around total knee arthroplasty. A Mayo Clinic report on the subject identified 102 fractures, 19 of which were intraoperative and 83 postoperative.¹⁶ The fractures occurred in 73 women and 29 men.

Intraoperative tibial fractures were observed during tibial preparation, trial reduction, and implant placement as well as during cement removal in revision total knee arthroplasty. Insertion and removal of long-stem implants accounted for

PERIPROSTHETIC PATELLAR FRACTURES

Almost all patellar fractures associated with primary total knee arthroplasty occur postoperatively, although patellar fractures can occur intraoperatively during revision surgery. In the Mayo Clinic joint registry, no intraoperative patellar fractures were identified in 16,906 primary total knee arthroplasties, and only 8 were reported in 2904 revision total knee arthroplasties (see Table 2).

The incidence of postoperative periprosthetic fractures varies in different series.10, 31, 44 Healy et

CONCLUSIONS

Periprosthetic fractures around the hip and knee arthroplasties are being seen with increasing frequency. The prevalence and risk factors for fracture vary by anatomic site. The frequency of certain fracture types and locations are technique or implant design specific, whereas for other fracture types and locations the frequency and cause relate to bone quality and risk of trauma. An emerging problem, fractures associated with periprosthetic bone loss and osteolysis have now been reported

References (56)

W.L. Healy et al.
Patellofemoral complications following total knee arthroplasty: Correlation with implant design and patient risk factors
J Arthroplasty
(1995)
R.D. Heekin et al.
Fractures through cystic lesions of the greater trochanter: A cause of late pain after cementless total hip arthroplasty
J Arthroplasty
(1996)
A.V. Lombardi et al.
Intercondylar distal femoral fracture: An unreported complication of posterior-stabilized total knee arthroplasty
J Arthroplasty
(1995)
A.F. Lynch et al.
Extensor mechanism complications following total knee arthroplasty
J Arthroplasty
(1987)
M.A. Mont et al.
Fractures of the ipsilateral femur after hip arthroplasty: A statistical analysis of outcome based on 487 patients
J Arthroplasty
(1994)
B.F. Morrey et al.
Complications with revision of the femoral component of total hip arthroplasty: Comparison between cemented and uncemented techniques
J Arthroplasty
(1992)
M.A. Ritter et al.
Tibial shaft fracture following tibial tubercle osteotomy
J Arthroplasty
(1996)
M.A. Ritter et al.
Anterior femoral notching and ipsilateral supracondylar femur fracture in total knee arthroplasty
J Arthroplasty
(1988)
R.E. Windsor et al.
Patellar fractures in total hip arthroplasty
J Arthroplasty
(1989)
R.K. Aaron et al.
Supracondylar fracture of the femur after total knee arthroplasty
Clin Orthop
(1987)

P. Adolphson et al.

Fractures of the ipsilateral femur after total hip arthroplasty

Arch Orthop Trauma

(1987)

R.K. Beals et al.

Periprosthetic fractures of the femur: An analysis of 93 fractures

Clin Orthop

(1996)

Berry DJ. Pelvic discontinuity in revision total hip arthroplasty. Bone Joint Surg 1998,...

J.S. Bethea et al.

Proximal femoral fractures following total hip arthroplasty

Clin Orthop

(1982)

G.W. Brick et al.

The patellofemoral component of total knee arthroplasty

Clin Orthop

(1988)

P.R. Cain et al.

Periprosthetic femoral fractures following total knee arthroplasty

Clin Orthop

(1986)

J.J. Callaghan

Periprosthetic fractures of the acetabulum during and following total hip arthroplasty

Instr Course Lect

(1998)

C.M. Christensen et al.

Management of intraoperative femur fractures associated with revision hip arthroplasty

Clin Orthop

(1989)

M.L. Clayton et al.

Patellar complications after total condylar arthroplasty

Clin Orthop

(1982)

P.H. Cooke et al.

Fractures of the femur in relation to cemented hip prostheses

J Bone Joint Surg Br

(1988)

R.W. Culp et al.

Supracondylar fracture of the femur following prosthetic knee arthroplasty

Clin Orthop

(1987)

A.M. DiGioia et al.

Periprosthetic fractures of the femur after total knee arthroplasty: A literature review and treatment algorithm

Clin Orthop

(1991)

J.J. Elting et al.

Preliminary report of impaction grafting for exchange femoral arthroplasty

Clin Orthop

(1995)

G.A. Engh et al.

Periprosthetic fractures adjacent to total knee implants: Treatment and clinical results

Instr Course Lect

(1998)

N.A. Felix et al.

Periprosthetic fractures of the tibia associated with total knee arthroplasty

Clin Orthop

(1997)

M.P. Figgle et al.

The results of treatment of supracondylar fracture above total knee arthroplasty

J Arthroplasty

(1990)

R.H. Fitzgerald et al.

The uncemented total hip arthroplasty: Intraoperative femoral fractures

Clin Orthop

(1988)

H.O. Fredin et al.

Femoral fracture following hip arthroplasty

Acta Orthop Scand

(1987)

Cited by (490)

Bisphosphonate Use May be Associated With an Increased Risk of Periprosthetic Hip Fracture
2024, Journal of Arthroplasty
Osteoporosis is common among patients undergoing primary total hip arthroplasty (THA). This study aimed to evaluate the effect of bisphosphonate treatment on osteoporotic patients undergoing primary THA.
Using a national database, 30,137 patients who had osteoporosis before primary elective THA were identified during 2010 to 2020. Patients undergoing nonelective THA and those using corticosteroids or other medications for osteoporosis were excluded. Bisphosphonate users and bisphosphonate naïve patients were matched 1:1 based on age, sex, Elixhauser comorbidity index, and a history of obesity, rheumatoid arthritis, tobacco use, and alcohol abuse. Kaplan–Meier and multivariate analyses were used to compare 2-year outcomes between groups.
Among matched cohorts of 9,844 patients undergoing primary THA, bisphosphonate use was associated with a significantly higher 2-year rate of periprosthetic fracture (odds ratio 1.29, 95% confidence interval 1.04 to 1.61, P = .022). There was a trend toward increased risk of any revision with bisphosphonate use (odds ratio 1.19, confidence interval 1.00 to 1.41, P = .056). Rates of infection, aseptic loosening, dislocation, and mortality were not statistically different between bisphosphonate users and bisphosphonate-naïve patients.
In osteoporotic patients, bisphosphonate use before primary THA is an independent risk factor for periprosthetic fracture. Additional longer-term data are needed to determine the underlying mechanism for this association and identify preventative measures.
Cemented Versus Cementless Femoral Fixation for Total Hip Arthroplasty Following Femoral Neck Fracture in Patients Aged 65 and Older
2024, Journal of Arthroplasty
Femoral neck fractures are common in individuals over 65, necessitating quick mobilization for the best outcomes. There's ongoing debate about the optimal femoral component fixation method in total hip arthroplasty (THA) for these fractures. Recent U.S. data shows a preference for cementless techniques in over 93% of primary THAs. Nonetheless, cemented fixation might offer advantages like fewer revisions, reduced periprosthetic fractures, lesser thigh pain, and enhanced long-term implant survival for those above 65. This study compares cementless and cemented fixation methods in THA, focusing on postoperative complications in patients aged 65 and older.
We analyzed a national database to identify patients aged 65+ who underwent primary THA for femoral neck fractures between 2016 and 2021, using either cementless (n = 2,842) or cemented (n = 1,124) techniques. A 1:1 propensity-matched analysis was conducted to balance variables such as age, sex, and comorbidities, resulting in two equally sized groups (n = 1,124 each). We evaluated outcomes like infection, venous thromboembolism (VTE), wound issues, dislocation, periprosthetic fracture, etc., at 90 days, 1 year, and 2 years post-surgery. A P-value < 05 indicated statistical significance.
The cemented group initially consisted of older individuals, more females, and higher comorbidity rates. Both groups had similar infection and wound complication rates, and aseptic loosening. The cemented group, however, had lower periprosthetic fracture rates (2.5 versus 4.4%, P = .02) and higher VTE rates (2.9 versus 1.2%, P = .01) at 90 days. After 1 and 2 years, the cementless group experienced more aseptic revision surgeries.
This study, using a large, national database and propensity-matched cohorts, indicates that cemented femoral component fixation in THA leads to fewer periprosthetic fractures and aseptic revisions, but a higher VTE risk. Fixation type choice should consider various factors, including age, sex, comorbidities, bone quality, and surgical expertise. This data can inform surgeons in their decision-making process.
Strikingly High Rates of Periprosthetic Joint Infection Following Revision Surgery for Periprosthetic Fractures Regardless of Surgery Timing
2024, Journal of Arthroplasty
Periprosthetic fractures following total hip arthroplasty (THA) often occur in the early postoperative period. Recent data has indicated that early revisions are associated with higher complication rates, particularly periprosthetic joint infection (PJI). The purpose of this study was to assess the effect of timing of periprosthetic fracture surgery on complication rates. We hypothesized that complication rates would be significantly higher in revision surgeries performed within 3 months of the index THA.
The Medicare Part A claims database was queried from 2010 to 2017 to identify patients who underwent surgery for a periprosthetic fracture following primary THA. Patients were divided based on time between index and revision surgeries: <1, 1 to 2, 2 to 3, 3 to 6, 6 to 9, 9 to 12, and >12 months. Complication rates were compared between groups using multivariate analyses to adjust for demographics, comorbidities, and types of revision surgery.
Of 492,340 THAs identified, 4,368 (0.9%) had a subsequent periprosthetic fracture requiring surgery: 1,725 (39.4%) at <1 month, 693 (15.9%) at 1 to 2 months, 202 (4.6%) at 2 to 3 months, 250 (5.7%) at 3 to 6 months, 134 (3.1%) at 6 to 9 months, 85 (19.4%) at 9 to12 months, and 1,279 (29.3%) at >12 months. The risk of PJI was 11.0% in the <1 month group, 11.1% at 1 to 2 months, 7.9% at 2 to 3 months, 6.8% at 3 to 6 months, 8.2% at 6 to 9 months, 9.4% at 9 to 12 months, and 8.5% at >12 months (P = .12). Adjusting for confounding factors, risk of PJI following periprosthetic fracture surgery was similar regardless of timing (P > .05). Rates of subsequent dislocation and aseptic loosening were also similar regardless of timing.
The risk of PJI following repeat surgery for a periprosthetic fracture was strikingly high regardless of timing (6.8 to 11.1%), underscoring the high-risk of complications.
Higher Annual Total Hip Arthroplasty Volume Decreases the Risk of Intraoperative Periprosthetic Femur Fractures
2024, Journal of Arthroplasty
Periprosthetic femur fracture (PFF) is a complication of total hip arthroplasty (THA). These occur intraoperatively or postoperatively, and documented risk factors of PFFs include women, age greater than 65 years, cementless stems, and inflammatory arthropathies. The aim of this retrospective cohort study was to assess the relationship of years of surgical experience and surgeon annual THA volume on intraoperative and postoperative PFFs.
Data were collected from a database query, and PFFs were identified as either intraoperative or postoperative. Intraoperative and postoperative PFFs were both compared to a control group of non-PFF patients. Years of surgical experience at the time of surgery and annual THA volume for the primary surgeon were calculated for all cases. Logistic regression analyses were used to calculate odds ratios for each of the surgeon variables when adjusted for patient demographics.
Thirty-seven intraoperative and 108 postoperative PFFs were identified and compared to 7,629 controls. From regression analyses, high-volume surgeons (≥50 THA/year) had lower odds of intraoperative PFF (adjusted odds ratio (aOR) = 0.40, P = .020) but not postoperative PFF (aOR = 1.02, P = .921). Surgeon experience (≥15 years since board certification at the time of surgery), was not significantly related to either PFF outcomes. For patient factors, age ≥65 years (aOR = 2.30, P < .001) and women (aOR = 2.69, P < .001) were both significant predictors of postoperative PFFs only.
Surgeons who performed 50 or more THAs per year had significantly fewer intraoperative PFFs than surgeons who did less than 50 THAs per year. Surgeon experience was not significantly related to PFFs.
Management of Intraoperative Acetabular Fractures During Total Hip Arthroplasty
2024, Orthopedic Clinics of North America
Treatment of Intraoperative Trochanteric Fractures During Primary and Revision Total Hip Arthroplasty
2024, Orthopedic Clinics of North America

View all citing articles on Scopus

: Address reprint requests to Daniel J. Berry, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905

^*: Mayo Clinic, Rochester, Minnesota

^*: Data from the Mayo Clinic joint registry are used in this article to provide figures on the relative frequency of different types of fractures (see Tables 1 and 2). The data do not provide absolute prevalence information because they represent all hip and knee arthroplasties done at the Mayo Clinic to date, some performed recently and some performed more than two decades ago. Furthermore, the data represent minimal figures because some fractures treated elsewhere may not have been identified. The data include only fractures identified after primary or revision total hip or knee arthroplasty done at the Mayo Clinic and do not include fractures referred for treatment after arthroplasty elsewhere. Finally, the figures represent raw data from the total joint registry, and each case has not been individually reviewed by the author.

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EPIDEMIOLOGY: Hip and Knee

Section snippets

Intraoperative

PERIPROSTHETIC FRACTURES AROUND TOTAL KNEE ARTHROPLASTY

PERIPROSTHETIC TIBIA FRACTURES

PERIPROSTHETIC PATELLAR FRACTURES

CONCLUSIONS

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

Supracondylar fracture of the femur after total knee arthroplasty

Clin Orthop

Fractures of the ipsilateral femur after total hip arthroplasty

Arch Orthop Trauma

Periprosthetic fractures of the femur: An analysis of 93 fractures

Clin Orthop

Proximal femoral fractures following total hip arthroplasty

Clin Orthop

The patellofemoral component of total knee arthroplasty

Clin Orthop

Periprosthetic femoral fractures following total knee arthroplasty

Clin Orthop

Periprosthetic fractures of the acetabulum during and following total hip arthroplasty

Instr Course Lect

Management of intraoperative femur fractures associated with revision hip arthroplasty

Clin Orthop

Patellar complications after total condylar arthroplasty

Clin Orthop

Fractures of the femur in relation to cemented hip prostheses

J Bone Joint Surg Br

Supracondylar fracture of the femur following prosthetic knee arthroplasty

Clin Orthop

Periprosthetic fractures of the femur after total knee arthroplasty: A literature review and treatment algorithm

Clin Orthop

Preliminary report of impaction grafting for exchange femoral arthroplasty

Clin Orthop

Periprosthetic fractures adjacent to total knee implants: Treatment and clinical results

Instr Course Lect

Periprosthetic fractures of the tibia associated with total knee arthroplasty

Clin Orthop

The results of treatment of supracondylar fracture above total knee arthroplasty

J Arthroplasty

The uncemented total hip arthroplasty: Intraoperative femoral fractures

Clin Orthop

Femoral fracture following hip arthroplasty

Acta Orthop Scand