title: Outcome after proximal femoral fractures during primary total hip replacement by the direct anterior approach.
abstract: BACKGROUND
  The literature suggests that intraoperative fractures of the greater trochanter and the metaphysis are increased with uncemented stems and the direct anterior approach. This study aims to determine the incidence and assess the functional and radiological outcome after such fractures.
  
  
  METHODS
  484 consecutive total hip replacements (THR) (64 ± 12 years) were analyzed. We treated trochanteric fractures conservatively without any further denuding, and secured metaphyseal fissures with cerclages. Postoperative X-rays and at the latest follow-up were compared to assess secondary fracture displacement and stem subsidence. Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores after 1 year were analyzed. For each patient sustaining a fracture, two patients without fractures were matched in terms of age, body mass index and gender.
  
  
  RESULTS
  13 (2.7 %, 5 male, 68 ± 9 years) patients with intraoperative fractures of the greater trochanter (n = 8) or the metaphysis (n = 5) were analyzed. Consolidation was observed in 7/8 patients sustaining a trochanteric fracture while secondary displacement of the fragment occurred in one case. Stem subsidence was observed in 2/5 cases (5 and 7 mm). Patients who sustained a fracture showed a trend towards poorer WOMAC scores at 1 year postoperatively, compared to patients without fractures. A significantly increased joint stiffness was also observed.
  
  
  CONCLUSIONS
  The intraoperative fracture risk in this series of THR through a direct anterior approach was 2.7 %. Trochanteric fractures do heal without primary fixation. Metaphyseal fractures heal well if immediately stabilized with a cerclage.
authors: Department of Orthopaedics, University of Zurich, Balgrist, Zurich, Switzerland. ortho@mm.st
authors: Hannes A
authors: HA
authors: Rüdiger
authors: Michael
authors: M
authors: Betz
authors: Patrick O
authors: PO
authors: Zingg
authors: John
authors: J
authors: McManus
authors: Claudio F
authors: CF
authors: Dora
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D005260:Female; D005264:Femoral Fractures / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery; D006620:Hip Fractures / Q000000981:diagnostic imaging / Q000209:etiology* / Q000601:surgery; D006801:Humans; D007431:Intraoperative Complications / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D057068:Periprosthetic Fractures / Q000000981:diagnostic imaging / Q000209:etiology* / Q000601:surgery; D011859:Radiography; D020127:Recovery of Function; D016896:Treatment Outcome