title: Periprosthetic fractures around a cementless hydroxyapatite-coated implant: a new fracture pattern is described.
abstract: BACKGROUND
  Periprosthetic fractures can occur both intraoperatively and postoperatively with implantation of cementless tapered stems.
  
  
  OBJECTIVE
  In a large cohort of patients receiving cementless, proximally hydroxyapatite-coated femoral implants, we answered the following questions: What was the incidence of intraoperative and postoperative fractures associated with the implant? What were the fracture patterns as classified by the Vancouver classification system? Did the Vancouver classification represent the fracture patterns found? How were the fractures treated and what were the treatment outcomes; that is, how many fractures healed and did the stems osseointegrate?
  
  
  METHODS
  We evaluated 1039 hips (932 patients) from three prospective studies. The hips were divided into three groups: no fractures, intraoperative fractures, and postoperative fractures. Demographic differences among the groups were noted. Postoperative fractures were classified using the Vancouver classification system. We judged stem stability using Engh's criteria and fracture union was determined by the treating surgeon and confirmed by the authors.
  
  
  RESULTS
  We identified 58 periprosthetic fractures in the 1039 hips (5.6%): 38 intraoperative (3.7%) and 20 postoperative (1.9%). Eleven of the postoperative fractures were classifiable by the original Vancouver classification system and nine were of the newly described "clamshell" variety, not classifiable by this system. No intraoperative fractures extended below the lesser trochanter. Twenty-five of these fractures were treated with a single cable or cerclage wire. The remaining received no specific treatment. Of the 20 postoperative fractures, five were treated nonoperatively. All stems osseointegrated.
  
  
  CONCLUSIONS
  Both intraoperative and postoperative fractures can be managed with success when the stem is stabilized or found to be osseointegrated. An adjustment to the Vancouver classification is suggested to include the clamshell fracture, which has not been previously described.
authors.affiliation: Department of Orthopaedic Surgery, Indiana University Medical Center, Clinical Building, Room 600, 541 Clinical Drive, Indianapolis, IN, 46202, USA, wcapello@iupui.edu.
authors.forename: William N
authors.initials: WN
authors.lastname: Capello
authors.forename: James A
authors.initials: JA
authors.lastname: D'Antonio
authors.forename: Marybeth
authors.initials: M
authors.lastname: Naughton
mesh_terms: D000328:Adult; D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects* / Q000295:instrumentation*; D016009:Chi-Square Distribution; D020099:Coated Materials, Biocompatible; D017886:Durapatite; D005260:Female; D005264:Femoral Fractures / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000601:surgery; D005269:Femur / Q000000981:diagnostic imaging / Q000601:surgery*; D005592:Fracture Fixation; D017102:Fracture Healing; D006621:Hip Joint / Q000000981:diagnostic imaging / Q000601:surgery*; D006622:Hip Prosthesis; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D016348:Osseointegration; D057068:Periprosthetic Fractures / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000601:surgery; D011474:Prosthesis Design; D011859:Radiography; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D020099:Coated Materials, Biocompatible; D017886:Durapatite