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Background: Periprosthetic fractures can be devastating complications after total joint arthroplasty (TJA). The management of periprosthetic fractures is complex, spanning expertise in arthroplasty and trauma. The purpose of this study was to examine and project trends in the operative treatment of periprosthetic fractures in the United States., Methods: A large, public and private payer database was queried to capture all International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for periprosthetic femoral and tibial fractures. Statistical models were created to assess trends in treatment for periprosthetic fractures and to predict future surgical rates. An alpha value of 0.05 was used to assess significance. A Bonferroni correction was applied where applicable to account for multiple comparisons., Results: In this study, from 2016 to 2021, 121,298 patients underwent surgical treatment for periprosthetic fractures. There was a significant increase in the total number of periprosthetic fractures. The incidence of periprosthetic hip fractures rose by 38% and that for periprosthetic knee fractures rose by 73%. The number of periprosthetic fractures is predicted to rise 212% from 2016 to 2032. There was a relative increase in open reduction and internal fixation (ORIF) compared with revision arthroplasty for both periprosthetic hip fractures and periprosthetic knee fractures., Conclusions: Periprosthetic fractures are anticipated to impose a substantial health-care burden in the coming decades. Periprosthetic knee fractures are predominantly treated with ORIF rather than revision total knee arthroplasty (TKA), whereas periprosthetic hip fractures are predominantly treated with revision total hip arthroplasty (THA) rather than ORIF. Both periprosthetic knee fractures and periprosthetic hip fractures demonstrated increasing trends in this study. The proportion of periprosthetic hip fractures treated with ORIF relative to revision THA has been increasing., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H943)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Femoral pin-site fracture is one of the most serious complications of navigation-assisted total knee arthroplasty (TKA). Its occurrence is associated with the loss of biomechanical strength caused by intraoperative femoral drilling. This study aimed to investigate the drilling location as a risk factor for pin-site fracture., Methods: A biomechanical analysis using rabbit femora was performed to determine the effects of drilling eccentricity and height. Torsional, 3-point bending, and axial compression tests were performed to evaluate biomechanical parameters, including failure strength, failure displacement, and stiffness. Fracture type and the presence of comminution were noted and analyzed. Finite-element analysis (FEA) was utilized to assess the stress distribution and deformation. The cumulative sum (CUSUM) method was applied to define the safe range for drilling eccentricity., Results: Drilling operations were accurately implemented. Biomechanical tests confirmed that severely eccentric drilling significantly reduced the biomechanical strength of the femur, especially in torsion. FEA results provided evidence of threatening stress concentration in severely eccentric drilling. The overall safe range of eccentricity relative to the center of the femur was found to be between 50% of the radius in the anterolateral direction and 70% of the radius in the posteromedial direction., Conclusions: Severely eccentric drilling significantly increased the risk of femoral pin-site fracture, especially under torsional stress. Femoral drilling should be performed in the safe zone that was identified., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H143)., (Copyright © 2022 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Background: Modular fluted tapered (MFT) stems have advanced treatment of Vancouver B2 and B3 periprosthetic femoral fractures, but series to date have been limited with respect to cohort size and follow-up duration. The purpose of this study was to determine implant survivorship, radiographic results, complications, and clinical outcomes of Vancouver B2 and B3 periprosthetic femoral fractures treated with MFT stems in a large series of patients., Methods: We identified 171 Vancouver B2 (109) and B3 (62) periprosthetic femoral fractures treated with an MFT stem between 2000 and 2018 using our institutional total joint registry. The mean age was 75 years, 50% were female, and the mean body mass index was 29 kg/m2. The median stem diameter was 18 mm and median stem length was 210 mm. The cumulative incidences of revision and reoperation with death as the competing risk were calculated, radiographs were reviewed, and clinical outcomes were evaluated using the Harris hip score (HHS). The mean follow-up was 5 years., Results: The 10-year cumulative incidence of any revision was 10%. There were 17 revisions, of which only 3 were for the distal fluted portion of the MFT stem. Revision indications included periprosthetic joint infection (PJI) (n = 6) and dislocation (n = 11). The 10-year cumulative incidence of any reoperation was 15%. In addition to the above 17 revisions, there were 7 reoperations for superficial wound complications (n = 4), Vancouver B1 periprosthetic femoral fracture (n = 1), vascular occlusion (n = 1), and acetabular cartilage degeneration requiring an acetabular component (n = 1). Radiographically, there was 1 fracture nonunion. All unrevised MFT stems were radiographically well fixed. Subsidence of ≥5 mm occurred in 11%, but all implants were stable at the most recent follow-up. The mean HHS was 75 at 2 years (n = 71)., Conclusions: In this large series of 171 Vancouver B2 and B3 periprosthetic femoral fractures treated with MFT stems, we found that such constructs were associated with a high rate of fracture healing and provided extremely reliable and durable implant fixation, with no revisions for aseptic loosening. Dislocation and PJI were the most common complications., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H64)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Periprosthetic fracture is a leading reason for readmission following total hip arthroplasty. Most of these fractures occur during the early postoperative period before bone ingrowth. Before ingrowth occurs, the femoral component can rotate relative to the femoral canal, causing a spiral fracture pattern. We sought to evaluate, in a paired cadaver model, whether the torsional load to fracture was higher in collared stems. The hypothesis was that collared stems have greater load to fracture under axial and torsional loads compared with collarless stems., Methods: Twenty-two cadaveric femora (11 matched pairs) with a mean age of 77 ± 10.2 years (range, 54 to 90 years) were harvested. Following dissection, the femora were evaluated with use of a dual x-ray absorptiometry scanner and T scores were recorded. We utilized a common stem that is available with the same intraosseous geometry with and without a collar. For each pair, 1 femur was implanted with a collared stem and the contralateral femur was implanted with a collarless stem with use of a standard broaching technique. A compressive 68-kg load was applied to simulate body weight during ambulation. A rotational displacement was then applied until fracture occurred. Peak torque prior to fracture was measured with use of a torque meter load cell and data acquisition software., Results: The median torque to fracture was 65.4 Nm for collared stems and 43.1 Nm for uncollared stems (p = 0.0014, Wilcoxon signed-rank test). The median T score was -1.95 (range, -4.1 to -0.15). The median difference in torque to fracture was 29.18 Nm. As expected in each case, the mode of failure was a spiral fracture around the implant., Conclusions: Collared stems seemed to offer a protective effect in torsional loading in this biomechanical model comparing matched femora., Clinical Relevance: These results may translate into a protective effect against early periprosthetic Vancouver B2 femoral fractures that occur before osseous integration has occurred.

Background: Mechanical failure of intramedullary nails is rare. This investigation was prompted by a series of cases of observed breakage of the recently introduced TFNA Proximal Femoral Nailing System (TFN [Trochanteric Fixation Nail]-Advanced; DePuy Synthes) in our region. Laboratory analysis and case data are presented, in contribution to post-market surveillance., Methods: Medical and imaging records from the 3 public tertiary orthopaedic trauma hospitals in Western Australia were reviewed. Relevant data of patients in whom breakage of the TFNA implant occurred between 2016 and 2018 were collected and analyzed. Laboratory review of retrieved implants was conducted at the Centre for Implant Technology and Retrieval Analysis (CITRA) in Western Australia., Results: A total of 16 cases of TFNA implant breakage were recorded and analyzed. The predominant OTA/AO fracture classification was 31A3 (12 cases, 75%). The reduction quality was good in 10 cases, acceptable in 4 cases, and poor in 2 cases. The mean time to failure (and standard deviation) was 5.0 ± 2.2 months (range, 2.2 to 9.8 months). The treatment modality for the breakage was revision nailing in 11 cases, arthroplasty in 3, and nonoperative management in 2. All nails broke at the proximal screw aperture, with 1 nail additionally breaking at the distal aperture. Of 8 patients treated with a second TFNA implant for nail breakage, 3 (38%) returned with breakage of the revision implant. Laboratory analysis of the broken nails demonstrated a unique fracture pattern, with a stepped propagation pathway., Conclusions: This study represents the largest series, to our knowledge, of proximal femoral nail breakages in the published English literature and is the first that we are aware of to involve laboratory analysis of the TFNA implant. Changes to the nail design and/or alloy may have contributed to the observed cases of breakage, and this study will be followed by an evaluation of breakage rates in comparison with those of previous generations of nailing systems. We advise close clinical and radiographic surveillance of patients with unstable hip fracture patterns who undergo osteosynthesis with use of a TFNA implant., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: The direct anterior approach for total hip arthroplasty (THA) is marketed with claims of superiority over other approaches. Femoral exposure can be technically challenging and potentially lead to early failure. We examined whether surgical approach is associated with early THA failure., Methods: A retrospective review of 478 consecutive early revision THAs performed within 5 years after the primary THAs at 3 academic centers from 2011 through 2014 was carried out. Exclusion criteria resulted in a final analysis sample of 342 early-failure THAs. The surgical approach of the primary operation that was revised, the time to the revision, and the etiology of the failure leading to the revision were documented., Results: Analysis of the revisions due to early femoral failure showed them to be more common in patients who had undergone the direct anterior approach (57/112; 50.9%) than in those treated with the direct lateral (39/112; 34.8%) or the posterior (16/112; 14.3%) approach (p = 0.001). In multivariate regression analysis controlling for age, sex, laterality, Dorr bone type, body mass index (BMI) at revision, bilateral procedure (yes/no), and femoral stem type, the direct anterior approach remained a significant predictor of early femoral failure (p = 0.007). The majority of early revisions due to instability were associated with the posterior (19/40; 47.5%) or direct anterior (15/40; 37.5%) approach (p = 0.001 for the comparison with the direct lateral approach [6/40; 15.0%])., Conclusions: Despite claims of earlier recovery and improved outcomes with the direct anterior approach for THA, our findings indicate that that approach may confer a greater risk of early femoral failure and, along with the posterior approach, confer a greater risk of early instability compared with the direct lateral approach., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Certain fracture configurations, especially spiral fractures, are often thought to be indicative of nonaccidental trauma in children. The purpose of this study was to determine whether femoral fracture morphology, as determined by an objective measurement (fracture ratio), was indicative of nonaccidental trauma in young children., Methods: Consecutive patients who were three years of age or younger and had a closed, isolated femoral shaft fracture treated at an urban pediatric level-I trauma center between 2005 and 2013 were identified. Anteroposterior and lateral fracture ratios (fracture length/bone diameter) were calculated for each patient by a fellowship-trained pediatric orthopaedic surgeon who was blinded to the patient's clinical history. The presence or absence of a Child Protective Services referral as well as institutional Child Assessment Program evaluations were reviewed. Nonaccidental trauma was deemed to be present, absent, or indeterminate by Child Protective Services or an on-site Child Assessment Program team. To further evaluate and quantify the likelihood of nonaccidental trauma, the criteria of the Modified Maltreatment Classification System were used., Results: Of 122 patients identified, ninety-five met the inclusion criteria for this study. Of these ninety-five, fifty-one (54%) had either a Child Protective Services or a Child Assessment Program consultation because of suspected nonaccidental trauma. Thirteen (25%) were found to have nonaccidental trauma as determined by Child Protective Services or the Child Assessment Program team and seven (14%) had indeterminate Child Protective Services or Child Assessment Program investigations. All thirteen patients with nonaccidental trauma, as well as the seven patients with an indeterminate Child Protective Services or Child Assessment Program investigation, had positive Modified Maltreatment Classification System scores for physical abuse. Patients who had nonaccidental trauma had significantly decreased mean anteroposterior fracture ratios compared with those who had confirmed accidental trauma (p < 0.0001)., Conclusions: The fracture ratio can be helpful to determine fracture morphology and can be used as part of the assessment of a child with suspected nonaccidental trauma. While not diagnostic, the presence of a transverse diaphyseal femoral fracture in a young child should raise the index of suspicion for nonaccidental trauma., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

➤ Pathologic fracture of the proximal part of the femur resulting from metastatic disease causes severe pain and an inability to walk. Surgical stabilization can be challenging because of bone loss resulting from the underlying metastatic lesions, the potential for major blood loss, and the poor health of the patient.➤ The goal of surgical treatment is the creation of a stable construct to allow early weight-bearing.➤ Pathologic femoral neck fractures secondary to metastases are best managed with arthroplasty.➤ The treatment of intertrochanteric or subtrochanteric fractures is more controversial. Surgical stabilization may be performed with cephalomedullary nailing or arthroplasty. The choice of implant and operative technique is dependent on careful consideration of multiple factors, including the patient's life span, the type of tumor, the perceived response to other therapies, the need for adjuvant radiation therapy and chemotherapy, the location and number of metastatic lesions, and the degree of bone involvement.➤ While the potential for complications is high, surgical stabilization of the proximal part of the femur decreases pain and improves function., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: There is increasing evidence associating "atypical" femoral fractures with prolonged exposure to bisphosphonate therapy. The cause of these fractures is unknown and likely multifactorial. This study evaluated the hypothesis that patients with primary osteoporosis who sustain atypical femoral fracture(s) while on chronic bisphosphonate therapy have a more varus proximal femoral geometry than patients who use bisphosphonates for primary osteoporosis but do not sustain a femoral fracture., Methods: The femoral neck-shaft angle was measured on the radiographs of 111 patients with atypical femoral shaft fracture(s) and thirty-three asymptomatic patients; both groups were on chronic bisphosphonate therapy. Patients with characteristic lateral cortical thickening, stress lines, and thigh pain were included in the fracture group., Results: The mean neck-shaft angle of the patients who sustained atypical femoral fracture(s) while taking bisphosphonates (case group) differed significantly from that of the patients on bisphosphonate therapy without a fracture (129.5° versus 133.8°; p < 0.001). Fifty-three (48%) of the patients in the case group had a neck-shaft angle that was lower than the lowest angle in the control group (128°). Side-to-side comparison in patients with a unilateral pathologic involvement and an asymptomatic contralateral lower limb did not demonstrate any significant difference between the neck-shaft angles in the two limbs., Conclusions: Patients on chronic bisphosphonate therapy who presented with atypical femoral fracture(s) had more varus proximal femoral geometry than those who took bisphosphonates without sustaining a fracture. Although no causative effect can be determined, a finding of varus geometry may help to better identify patients at risk for fracture after long-term bisphosphonate use., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: We used the Nordic Arthroplasty Register Association database to evaluate whether age, sex, preoperative diagnosis, fixation, and implant design influence the risk of revision arthroplasty due to periprosthetic fracture within two years from operation of a primary total hip replacement., Methods: Included in the study were 325,730 cemented femoral stems and 111,899 uncemented femoral stems inserted from 1995 to 2009. Seven frequently used stems (two cemented stems [Exeter and Lubinus SP II] and five uncemented stems [Bi-Metric, Corail, CLS Spotorno, ABG I, and ABG II]) were specifically studied., Results: The incidence of revision at two years was low: 0.47% for uncemented stems and 0.07% for cemented stems. Uncemented stems were much more likely to have this complication (relative risk, 8.72 [95% confidence interval, 7.37 to 10.32]; p < 0.0005). Age had no consistent influence on the risk for revision of cemented stems, but revision in the uncemented group increased with increasing age. A cemented stem was associated with a higher risk in male patients compared with female patients (hazard ratio, 1.95 [95% confidence interval, 1.51 to 2.53]; p < 0.0005), whereas an uncemented stem was associated with a reduced risk in male patients compared with female patients (hazard ratio, 0.74 [95% confidence interval, 0.62 to 0.89]; p = 0.001). The risk for revision due to early periprosthetic fracture increased during the 2003 to 2009 period compared with the 1995 to 2002 period both before and after adjustment for demographic factors and fixation (relative risk, 1.44 [95% confidence interval, 1.18 to 1.69]; p < 0.0005). The hazard ratio for the Exeter stem was about five times higher than that for the Lubinus SP II stem (hazard ratio, 5.03 [95% confidence interval, 3.29 to 7.70]; p < 0.0005). Of the five uncemented stems, the ABG II stem showed an increased hazard ratio of 1.63 (95% confidence interval, 1.16 to 2.28) (p = 0.005), whereas the Corail stem showed a decreased hazard ratio of 0.47 (95% confidence interval, 0.34 to 0.65) (p < 0.0005) compared with the reference Bi-Metric design., Conclusions: The shape and surface finish of the femoral stem and its fixation could be related to the increased risk of some prosthetic designs. Even if the incidence of early periprosthetic fracture in general is low and other reasons for revision must be considered, specific attention should be given to the choice of fixation and stem design in risk groups., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Systemic administration of sclerostin neutralizing antibody has led to increased bone formation in animal models of osteoporosis. The purpose of this study was to determine if systemic administration of sclerostin neutralizing antibody could increase the healing response in a critical-sized femoral defect in rats., Methods: Critical-sized femoral defects were created in Lewis rats, and the rats were randomized into four groups. The sclerostin antibody (Scl-Ab) treatment groups included the continuous Scl-Ab group (twenty-one animals), the early Scl-Ab group (fifteen animals), and the delayed Scl-Ab group (fifteen animals), which received sclerostin antibody (25 mg/kg) twice weekly for weeks 0 through 12; weeks 0 through 2; and weeks 2 through 4; respectively. Twenty-one animals in the control group received vehicle from weeks 0 through 12. In a subsequent study, bone turnover markers were measured at zero, two, six, and twelve weeks after surgery in rats receiving vehicle or sclerostin neutralizing antibody for twelve weeks (fifteen rats per group). The quality of bone formed was evaluated with radiographs, microcomputed tomography, biomechanical testing, and histologic and histomorphometric analysis., Results: In the primary study, four of fifteen defects in the continuous (zero to twelve-week) Scl-Ab group, three of fifteen defects in the early (zero to two-week) Scl-Ab group, and four of fifteen defects in the delayed (two to four-week) Scl-Ab group healed at twelve weeks, while none of the defects healed in the control group. In both studies, treatment with sclerostin antibody for twelve weeks demonstrated a significant increase in new bone formation (p < 0.05) compared with the control group. The three treatment groups did not differ significantly with respect to the healing rates and the quality of new bone formed in the defect. The serum markers of bone formation were significantly elevated in the animals in the continuous Scl-Ab group (p < 0.05) compared with the controls., Conclusions: Administration of sclerostin neutralizing antibody led to increased bone formation, resulting in complete healing of femoral defects in a small subset of rats, with a majority of the animals not healing the defect by twelve weeks.

Background: The Surgical Implant Generation Network (SIGN) intramedullary nailing system was designed to treat femoral fractures in developing countries where real-time imaging, power equipment, and fracture tables are often not available. We performed a retrospective analysis of prospectively collected data on femoral shaft fractures treated with the SIGN intramedullary nailing system., Methods: Seventy consecutive patients with a closed diaphyseal femoral fracture were treated with the SIGN intramedullary nail at Mulago National Hospital in Uganda between February 2007 and March 2008, and fifty of these patients (the study cohort) were followed for at least six months or until fracture-healing., Results: The mean time to surgery was 13.2 days (range, zero to thirty-three days). All fractures healed, although two required dynamization for treatment of delayed union. No hardware failures occurred. An interlocking screw missed the nail in two patients, but both fractures healed without complications. One superficial and one deep infection developed; the latter required nail removal after fracture union. Including these patients, complications requiring further treatment occurred in 14% (seven) of the fifty patients., Conclusions: The SIGN intramedullary nailing system promotes predictable healing of femoral fractures in settings with limited resources including lack of real-time imaging, lack of power reaming, and delayed presentation to the operating room.

Background: Fixation of distal femoral fractures remains a challenge, especially in osteoporotic bone. This study was performed to investigate the biomechanical stability of four different fixation devices for the treatment of comminuted distal femoral fractures in osteoporotic bone., Methods: Four fixation devices were investigated biomechanically under torsional and axial loading. Three intramedullary nails, differing in the mechanism of distal locking (with two lateral-to-medial screws in one construct, one screw and one spiral blade in another construct, and four screws [two oblique and two lateral-to-medial with medial nuts] in the third), and one angular stable plate were used. All constructs were tested in an osteoporotic synthetic bone model of an AO/ASIF type 33-C2 fracture. Two nail constructs (the one-screw and spiral blade construct and the four-screw construct) were also compared under axial loading in eight pairs of fresh-frozen human cadaveric femora., Results: The angular stable plate constructs had significantly higher torsional stiffness than the other constructs; the intramedullary nail with four-screw distal locking achieved nearly comparable results. Furthermore, the four-screw distal locking construct had the greatest torsional strength. Axial stiffness was also the highest for the four-screw distal locking device; the lowest values were achieved with the angular stable plate. The ranking of the constructs for axial cycles to failure was the four-screw locking construct, with the highest number of cycles, followed by the angular stable plate, the spiral blade construct, and two-screw fixation. The findings in the human cadaveric bone were comparable with those in the synthetic bone model. Failure modes under cyclic axial load were comparable for the synthetic and human bone models., Conclusions: The findings of this study support the concept that, for intramedullary nails, the kind of distal interlocking pattern affects the stabilization of distal femoral fractures. Four-screw distal locking provides the highest axial stability and nearly comparable torsional stability to that of the angular stable plate; the four-screw distal interlocking construct was found to have the best combined (torsional and axial) biomechanical stability.

Intraoperative periprosthetic fractures are becoming more common given the increased prevalence of revision total hip arthroplasty and increased use of cementless fixation. Risk factors for intraoperative periprosthetic fractures include the use of minimally invasive techniques; the use of press-fit cementless stems; revision operations, especially when a long cementless stem is used or when a short stem with impaction allografting is used; female sex; metabolic bone disease; bone diseases leading to altered morphology such as Paget disease; and technical errors at the time of the operation. Appropriate treatment of intraoperative periprosthetic fractures does not compromise the long-term results of total hip arthroplasty unless the bone damage precludes stable fixation of the implant.

Background: Following revision total hip arthroplasty involving femoral impaction grafting, fractures usually have occurred distal to a standard-length stem in an area of weakened bone that was left inadequately supported. The purpose of the present study was to determine whether the use of a long stem decreases the rate of femoral fracture after revision hip surgery. We hypothesized that the use of a long-stem femoral component would decrease the risk of these fractures., Methods: From 1991 to 2000, 567 revision total hip arthroplasties were performed with use of femoral impaction grafting. Of these, forty-two procedures in forty patients (average age, 73.8 years) were performed with use of a stem that was > or = 220 mm in length. The average number of previous revisions was 1.85. Thirty-four of the forty hips with preoperative radiographs had preoperative bone loss that was classified as grade III or IV according to the Endo-Klinik system. Major complications were recorded, and survival analysis was performed., Results: No patient was lost to follow-up. Sixteen patients (sixteen hips) died at an average of fifty-two months postoperatively. The average duration of clinical follow-up for the hips in which the implant survived for more than forty-eight months was 7.5 years. The rate of major postoperative complications was 29%. Two postoperative femoral fractures occurred. Six patients (six hips) required a femoral reoperation. The survival rate with revision hip surgery as the end point was 90% at both five and ten years. The rate of survival with any failure as the end point was 82% at five years and 64% at ten years., Conclusions: The use of a long stem for femoral impaction grafting did not completely resolve the problem of postoperative fractures in these patients with substantial loss of bone stock undergoing revision hip surgery. Poor bone stock, technical errors, and other patient-related factors continue to account for the high postoperative fracture rate.

Background: Diaphyseal and distal femoral fractures are painful injuries that are frequently seen in patients requiring a trauma work-up in the hospital emergency department prior to definitive management. The purpose of this study was to determine whether a femoral nerve block administered in the emergency department could provide better pain relief for patients with femoral fractures than currently used pain management practices., Methods: Patients who presented with an acute diaphyseal or distal femoral fracture were identified as potential candidates for this study. Eligible patients were randomized by medical record number to receive either (a) the femoral nerve block (20 mL of 0.5% bupivacaine) along with standard pain management or (b) standard pain management alone (typically intravenous narcotics). The pain was assessed with use of a visual analog scale at the initial evaluation and at five, fifteen, thirty, sixty, and ninety minutes following the initial evaluation. Fifty-four patients were enrolled in the study from April 2005 to May 2006. Thirty-one patients received a femoral nerve block, and twenty-three patients received standard pain management alone., Results: Baseline scores on the visual analog pain scale did not differ between the groups at the initial evaluation. The patients who received a femoral nerve block (along with standard pain management) had significantly lower pain scores at five, fifteen, thirty, sixty, and ninety minutes following the block than did the patients who received standard pain management alone (p < 0.001). The score on the visual analog pain scale across these time-points was an average of 3.6 points less (on a 10-point scale) for those who received the block. There were no infections, paresthesias, or other complications related to the femoral nerve block., Conclusions: The acute pain of a diaphyseal or distal femoral fracture can be significantly decreased through the use of a femoral nerve block which can be administered safely in the hospital emergency department.

Background: Intramedullary fixation with use of a telescopic rod with a T-piece is one of the standard methods for long-bone stabilization in growing children with osteogenesis imperfecta. However, installation and removal of this device can cause substantial damage to the distal joint, which limits its use, especially in the tibia. We devised a modification of the telescopic rod system--the interlocking telescopic rod--in which the obturator is a simple rod with a hole, instead of a T-piece, at its distal end., Methods: The clinical and radiographic outcomes were evaluated more than two years following treatment of thirty-two limb segments (twenty-three tibiae and nine femora) with this new rod system in fifteen patients with osteogenesis imperfecta., Results: All rods were inserted without an arthrotomy of the distal joint, and all telescoped successfully. The interlocking pin used in the first five limb segments backed out between five and thirty-three months postoperatively. A revised fixation technique was used in the remaining twenty-seven limb segments, and the interlocking pin had not backed out at an average 3.1 years postoperatively. Proximal migration of the obturator was observed in four tibiae after 2.5 years. The cumulative survival rate of the rod at four years postoperatively was 88.7%., Conclusions: Both insertion and removal of an interlocking telescopic rod are much less invasive than insertion and removal of a conventional telescopic rod with a T-piece anchor. The interlocking pin at the distal epiphysis provides effective anchorage for telescoping. Our interim results showed survival of the device to be comparable with, or better than, that of the conventional telescopic rod.

Background: Periprosthetic femoral fractures following total hip arthroplasty are becoming more prevalent. When a fracture occurs in a femur with substantial proximal bone deficiency, the surgical options for revision are limited. One option includes the use of a proximal femoral allograft., Methods: We retrospectively assessed the results and complications of the use of a proximal femoral allograft to treat twenty-five Vancouver type-B3 periprosthetic fractures in twenty-four patients. The mean duration of follow-up was 5.1 years. Clinical results were graded with use of the Harris hip score. Radiographs were assessed for evidence of trochanteric union, host-allograft union, allograft resorption, and component loosening or fracture. Failure of the procedure was defined as the need for revision surgery requiring graft removal., Results: The mean postoperative Harris hip score was 70.8. At the time of the final follow-up, twenty-one of the twenty-four patients reported no or mild pain and twenty-three patients were able to walk; fifteen required a walking aid. The greater trochanter united in seventeen of the twenty-five hips (68%), and osseous union of the allograft to the host femur occurred in twenty hips (80%). There was mild graft resorption in four hips and moderate graft resorption in two. Four (16%) of the twenty-five hips required repeat revision., Conclusions: The use of a proximal femoral allograft for the treatment of a Vancouver type-B3 periprosthetic femoral fracture can provide a satisfactory result in terms of pain relief and function at five years.

Background: The application of indirect reduction techniques has improved fracture-healing and reduced the need for bone-grafting compared with the outcomes of older, direct reduction techniques. We investigated the results of such indirect reduction techniques for the treatment of periprosthetic femoral shaft fractures., Methods: Fifty consecutive patients with a femoral shaft fracture about a stable intramedullary implant (a Vancouver Type-B1 fracture) were treated with a protocol that included open reduction with use of indirect reduction techniques and internal fixation with a single lateral plate without structural allografting or other bone-grafting. Four patients died in the early postoperative period, and five had inadequate follow-up. The remaining forty-one patients (average age, seventy-two years) were evaluated clinically and radiographically at an average of twenty-four months., Results: All fractures healed in satisfactory alignment at an average of twelve weeks (range, seven to twenty-three weeks) after the index procedure. One patient had one fractured cable and two others had one fractured screw, but all of the fractures healed without evidence of implant loosening or malalignment. There was one deep infection in the perioperative period. Thirty of the forty-one patients returned to their baseline ambulatory status., Conclusions: The results of this study support the use of indirect open reduction and internal fixation with a single extraperiosteal lateral plate, without the use of allograft struts, for the treatment of a femoral shaft fracture about a stable intramedullary implant.

Background: Periprosthetic femoral fractures following total hip arthroplasty are becoming more prevalent. When a fracture occurs in a femur with substantial proximal bone deficiency, the surgical options for revision are limited. One option includes the use of a proximal femoral allograft., Methods: We retrospectively assessed the results and complications of the use of a proximal femoral allograft to treat twenty-five Vancouver type-B3 periprosthetic fractures in twenty-four patients. The mean duration of follow-up was 5.1 years. Clinical results were graded with use of the Harris hip score. Radiographs were assessed for evidence of trochanteric union, host-allograft union, allograft resorption, and component loosening or fracture. Failure of the procedure was defined as the need for revision surgery requiring graft removal., Results: The mean postoperative Harris hip score was 70.8. At the time of the final follow-up, twenty-one of the twenty-four patients reported no or mild pain and twenty-three patients were able to walk; fifteen required a walking aid. The greater trochanter united in seventeen of the twenty-five hips, and osseous union of the allograft to the host femur occurred in twenty hips. There was mild graft resorption in four hips and moderate graft resorption in two. Four (16%) of the twenty-five hips required repeat revision., Conclusions: The use of a proximal femoral allograft for the treatment of a Vancouver type-B3 periprosthetic femoral fracture can provide a satisfactory result in terms of pain relief and function at five years.

Background: The optimal surgical treatment for patients with high congenital dislocation of the hip remains controversial. The purpose of our study was to evaluate the mid-term to long-term results of cementless total hip arthroplasty in such patients., Methods: The study included sixty-eight total hip replacements performed between 1989 and 1994 in fifty-six consecutive patients with high congenital hip dislocation at our hospital. The cup was placed at the level of the true acetabulum, and a shortening osteotomy of the proximal part of the femur and distal advancement of the greater trochanter were performed in 90% of the hips. At the time of final follow-up, at a mean of 12.3 years postoperatively, fifty-two patients (sixty-four hips) were evaluated by us with a physical examination, determination of Harris hip scores, and radiographs., Results: The mean Harris hip score increased from 54 points preoperatively to 84 points at the time of final follow-up (p < 0.001). There was a negative Trendelenburg sign in fifty-nine (92%) of the sixty-four hips. There were thirteen perioperative complications (19%): three peroneal nerve palsies, one femoral nerve palsy, one superior gluteal nerve palsy, four nondisplaced fractures of the proximal part of the femur, one malpositioned stem perforating the posteromedial cortex of the femur, one superficial wound infection, and two early dislocations. With revision because of aseptic loosening as the end point, the ten-year survival rate for press-fit, porous-coated acetabular components was 94.9% (95% confidence interval, 89.3% to 100%). Eight of nine threaded acetabular components were revised, and the ninth was radiographically loose at the time of the last follow-up examination. The rate of survival for the CDH femoral components, with revision because of aseptic loosening as the end point, was 98.4% (95% confidence interval, 96.8% to 100%) at ten years., Conclusions: Total hip arthroplasty, with placement of the cup at the level of the true acetabulum, distal advancement of the greater trochanter, and femoral shortening osteotomy, can be recommended for patients with high congenital hip dislocation. Complications such as wear, osteolysis, and cup revision were secondary to the suboptimal design of the acetabular components used in this series.

Background: The treatment of a supracondylar femoral fracture following total knee arthroplasty is complicated by the presence of the prosthetic components. Anterior femoral notching during arthroplasty has been implicated as a contributing risk factor for femoral fracture. We retrospectively reviewed the effect of anterior femoral notching on the subsequent occurrence of a periprosthetic supracondylar fracture of the distal aspect of the femur and the outcomes of primary total knee arthroplasty in such patients., Methods: The prevalence and depth of femoral notching were determined on a review of the lateral radiographs by observers blinded to the clinical results of 1089 consecutive total knee replacements performed in 1997 and 1998. Linear and logistic regression modeling was used to analyze the relationship between femoral notching and the prevalence of supracondylar femoral fracture, postoperative range of motion, the Knee Society score, and the Knee Society functional and pain scores., Results: Femoral notching was performed in 325 (29.8%) of the 1089 knees in our series. During an average follow-up period of 5.1 years, only two supracondylar femoral fractures occurred, both in femora treated without notching. Femoral notching was not associated with an increased rate of fracture (p = 1.000) or with significant differences in the measures of outcome (range of motion [p = 0.117], knee score [p = 0.967], functional score [p = 0.861], need for a lateral release [p = 0.234], or postoperative pain [p = 0.948])., Conclusions: This study demonstrated no difference in knees managed with or without notching of the anterior distal aspect of the femur with respect to the occurrence of a supracondylar fracture, range of motion, Knee Society score, Knee Society function, or pain.

Background: The application of indirect reduction techniques has improved fracture-healing and reduced the need for bone-grafting compared with the outcomes of older, direct reduction techniques. We investigated the results of such indirect reduction techniques for the treatment of periprosthetic femoral shaft fractures., Methods: Fifty consecutive patients with a femoral shaft fracture about a stable intramedullary implant (a Vancouver Type-B1 fracture) were treated with a protocol that included open reduction with use of indirect reduction techniques and internal fixation with a single lateral plate without structural allografting or other bone-grafting. Four patients died in the early postoperative period, and five had inadequate follow-up. The remaining forty-one patients (average age, seventy-two years) were evaluated clinically and radiographically at an average of twenty-four months., Results: All fractures healed in satisfactory alignment at an average of twelve weeks (range, seven to twenty-three weeks) after the index procedure. One patient had one fractured cable and two others had one fractured screw, but all of the fractures healed without evidence of implant loosening or malalignment. There was one deep infection in the perioperative period. Thirty of the forty-one patients returned to their baseline ambulatory status., Conclusions: The results of this study support the use of indirect open reduction and internal fixation with a single extraperiosteal lateral plate, without the use of allograft struts, for the treatment of a femoral shaft fracture about a stable intramedullary implant., Level of Evidence: Therapeutic Level IV.

Background: In revision total hip arthroplasty, intraoperative split fractures and cortical perforation fractures are becoming a more common concern with the increasing use of diaphyseal fitting cementless stems. The purpose of this study was to evaluate the risk factors and frequency of intraoperative fractures with the use of these stems and their effect on radiographic and functional outcomes., Methods: We performed a retrospective case-control study of 211 consecutive patients who had undergone revision hip arthroplasty with a diaphyseal fitting cementless stem between December 1998 and March 2002. Sixty-four patients sustained an intraoperative fracture of the femur. One hundred and fifteen patients were followed for a minimum of two years; function was analyzed with self-administered outcome questionnaires, and radiographs were evaluated for evidence of bone ingrowth into the femoral stem., Results: Risk factors associated with an intraoperative fracture were a substantial degree of preoperative bone loss, a low femoral cortex-to-canal ratio, underreaming of the cortex, and the use of a large-diameter stem. The majority of the diaphyseal undisplaced linear fractures occurred at the distal end of an extended trochanteric osteotomy during stem insertion. Fracture due to cortical perforation occurred most often during cement removal. These intraoperative fractures had no significant effect on the functional outcome or radiographic evidence of bone ingrowth., Conclusions: There was a surprisingly high rate of intraoperative femoral fractures associated with the use of a diaphyseal fitting stem in revision total hip arthroplasty. Identification of risk factors such as preoperative bone loss and a low cortex-to-canal ratio may permit planning to avoid such fractures. However, the final functional and radiographic outcomes appear to have been unaffected by the fracture when it had been managed appropriately., Level of Evidence: Prognostic study, Level II-1 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Background: Revision total hip arthroplasty is indicated for most periprosthetic fractures that occur around the stem of the femoral implant. The purpose of the present study was to assess the results and complications of revision total hip arthroplasty for the treatment of periprosthetic femoral fractures., Methods: We evaluated 118 hips in 116 patients who underwent revision total hip arthroplasty because of an acute Vancouver type-B periprosthetic femoral fracture. The femoral implant used for the revision was a cemented stem in forty-two hips, a proximally porous-coated uncemented stem in twenty-eight, an extensively porous-coated stem in thirty, and an allograft-prosthesis composite or tumor prosthesis in eighteen. The mean duration of follow-up was 5.4 years., Results: Kaplan-Meier analysis demonstrated that the probability of survival was 90% at five years and 79.2% at ten years with revision or removal of the femoral implant for any reason as the end point. Sixteen femoral components were rerevised: ten were rerevised because of loosening; three, because of loosening in association with a fracture nonunion; two, because of recurrent dislocation; and one, because of a new periprosthetic fracture. Additionally, six femoral implants were resected because of deep infection (five) or prosthetic loosening (one). Radiographs of the ninety-six hips with a surviving implant showed that twenty-one had evidence of loosening of the femoral implant, four had a nonunion of the femoral fracture, and two had both a nonunion and loosening of the femoral implant., Conclusions: Revision total hip arthroplasty for the treatment of a periprosthetic fracture around the stem of the femoral implant successfully restored function for most patients. The greatest long-term problems were prosthetic loosening and fracture nonunion. Better results were seen when an uncemented, extensively porous-coated stem was used.

Background: The management of periprosthetic femoral fractures after total hip and knee replacement remains difficult and controversial. This study was performed to determine the results of Mennen plate fixation for the treatment of periprosthetic femoral fractures., Methods: This retrospective multicenter study consists of a review of a consecutive series of thirty-five patients in whom a total of thirty-six periprosthetic femoral fractures were treated with Mennen plate fixation. The average duration of follow-up was twenty-seven months (range, eight to forty-six months)., Results: Twenty-six fractures (72%) had united at an average of five months (range, three to ten months) after surgery. One of them had varus bending (10 degrees) of the plate. The remaining ten fractures had a nonunion and varus bending (20 degrees to 30 degrees) of the plate, with a fracture of the plate in eight. A revision procedure was successfully performed in the eight patients with nonunion., Conclusions: The treatment of unstable periprosthetic femoral fractures with Mennen plate fixation was complicated by high rates of mechanical failure (31%) and nonunion (28%). For this reason, we do not recommend the use of the Mennen plate for the treatment of periprosthetic femoral fractures.

Background: The use of impacted morselized allograft bone and cement in hip revision arthroplasty has been popular, but studies that specifically address intraoperative and postoperative complications have been scarce., Methods: All complications that occurred during, and within the first year after, 144 consecutive hip revision arthroplasties (108 stems and 130 sockets) performed with impacted morselized allograft bone and cement were recorded. Clinical and radiographic follow-up evaluation was performed at three months and at one year after surgery for all patients except eight (seven who had died of causes unrelated to the hip surgery and one who had sustained a stroke). Of these eight patients, seven had a six-week and/or three-month follow-up evaluation., Results: Thirty-nine femoral fractures occurred in thirty-seven hips; twenty-nine of the fractures occurred during surgery and ten, within five months after surgery. Of the intraoperative femoral fractures, twelve were proximal, nine were diaphyseal, and eight involved the greater trochanter. Of the postoperative femoral fractures, one was proximal and nine were diaphyseal. Other intraoperative complications were the creation of a femoral cortical window in seven hips and incidental perforation of the femoral cortex in fourteen. Multivariate analysis showed the risk factors for femoral fracture during or after revision to be concomitant disease, greater deficiency of the femoral bone stock, and an intraoperative femoral window or perforation. Other complications included dislocation of the femoral head in nine hips, deep infection in one hip, persistence of preoperative deep infection in one hip, and superficial wound infection requiring wound débridement in two hips., Conclusions: We found the complication rate to be high after hip revision arthroplasty performed with impacted morselized allograft bone and cement. The most serious complication was postoperative diaphyseal femoral fracture.

Background: Most hip fractures are treated surgically, with use of either internal fixation or prosthetic replacement of the femoral head. The presence of these implants increases the risk of a later femoral fracture in susceptible osteoporotic patients. The purpose of this study was to analyze the incidence of and risk factors for implant-related fractures of the femur after previous hip fracture surgery., Methods: Over a ten-year period from January 1988 to December 1997, 6230 patients (median age, eighty-two years; male:female ratio, 1247:4983) who sustained a total of 6696 hip fractures were admitted to the Edinburgh Orthopaedic Trauma Unit. Demographic information on the patients and details of the original treatment of the hip fracture were prospectively coded and entered into a trauma database. All subsequent readmissions due to a femoral fracture related to the implant were prospectively audited and extracted for the purposes of this study., Results: One hundred and forty-one patients sustained an ipsilateral fracture of the femur at a median of twenty-four weeks following the original hip fracture surgery. Survivorship analysis of the hip fracture population revealed an overall rate of subsequent femoral fracture of 2.9% at five years, which increased to 5.1% at ten years. The median age and gender distribution of the patients who sustained a subsequent femoral fracture were similar to those of the hip fracture population as a whole. Two-thirds of the fractures propagated from the tip of the implant. Analysis of the subsequent fractures according to the type of implant used to treat the original fracture revealed considerable differences in incidence. The incidence was relatively high in the patients initially treated with a Gamma nail (18.74 fractures per 1000 person-years) or a cementless hemiarthroplasty (11.72 per 1000 person-years) and was relatively low in those treated with a compression hip screw (4.46 per 1000 person-years), cannulated screws (4.50 per 1000 person-years), or a primary arthroplasty with cement (6.2 per 1000 person-years). The highest incidence of fracture was seen in the patients who had required an arthroplasty with cement as a revision procedure following failure of a primary implant (22.39 per 1000 person-years)., Conclusions: Implant-related fractures following hip fracture surgery are more common than has previously been appreciated. The risk of later ipsilateral femoral fracture is increased by the use of a Gamma nail or a cementless hemiarthroplasty to treat the original hip fracture.

Background: Periprosthetic femoral fractures around hip replacements are increasingly common. When the femoral component is stable, open reduction and internal fixation is recommended in all but exceptional cases. The purpose of this study was to evaluate the outcome of treatment of fractures around stable implants with cortical onlay strut allografts with or without a plate., Methods: A survey of our four centers identified forty patients with a fracture around a well-fixed femoral stem treated with cortical onlay strut allografts without revision of the femoral component. There were fourteen men and twenty-six women, with an average age of sixty-nine years. Nineteen patients were treated with cortical onlay strut allografts alone, and twenty-one were managed with a plate and one or two cortical struts. All of the patients were followed until fracture union or until a reoperation was done. The mean duration of follow-up was twenty-eight months for thirty-nine patients. One patient, who was noncompliant with treatment recommendations, had a failure at two months because of a fracture of the plate and graft. The primary end point of the evaluation was fracture union; secondary end points included strut-to-host bone union, the amount of final bone stock, and postoperative function., Results: Thirty-nine (98%) of the forty fractures united, and strut-to-host bone union was typically seen within the first year. There were four malunions, all of which had <10 degrees of malalignment, and one deep infection. There was no evidence of femoral loosening in any patient. All but one of the surviving patients returned to their preoperative functional level within one year., Conclusions: Cortical onlay strut allografts act as biological bone plates, serving both a mechanical and a biological function. The use of cortical struts, either alone or in conjunction with a plate, led to a very high rate of fracture union, satisfactory alignment, and an increase in femoral bone stock at the time of short-term follow-up. Although this study did not address the potential for later allograft remodeling, our findings suggest that cortical strut grafts should be used routinely to augment fixation and healing of a periprosthetic femoral fracture.

Background: Notching of the anterior femoral cortex during total knee arthroplasty has been implicated as a cause of subsequent periprosthetic supracondylar femoral fracture. However, other than observational clinical data, no reliable association between these events has been established, to our knowledge. The purpose of the present study was to investigate the biomechanical effects of notching of the anterior femoral cortex., Methods: The femoral component of a total knee replacement was implanted in twelve matched pairs of human cadaveric femora; one specimen in each pair had preservation of the anterior femoral cortex, and the other had a full-thickness cortical defect created just proximal to the anterior flange of the femoral component. The pairs were then subjected to either bending or torsional loading to failure. Both the fracture pattern and the quantitative load to failure were analyzed. Two matched pairs were excluded from the analysis because of inadvertent fracture during placement of the component., Results: Following the application of a bending load, femora with notching of the anterior femoral cortex sustained a short oblique fracture that originated at the cortical defect proximal to the femoral component and femora without notching had a midshaft fracture. In contrast, notching of the anterior femoral cortex had no effect on the fracture pattern that was observed after the application of a torsional load. The mean load to failure was significantly reduced by notching in both testing modes. Notching decreased bending strength from 11,813 to 9690 newtons (18 percent; p = 0.0034), and it decreased torsional strength from 134.7 to 81.8 newton-meters (39.2 percent; p = 0.01)., Conclusions: Biomechanical testing demonstrated that notching of the anterior femoral cortex significantly lessens the load to failure following total knee arthroplasty and influences the subsequent fracture pattern. These effects are manifested in different ways under the two loading conditions: the fracture pattern is altered under bending load, and there is a greater quantitative decrease in load to failure with torsional loading., Clinical Relevance: Weakening of the femur by notching of the anterior cortex after total knee arthroplasty may warrant alteration in the customary postoperative regimen for these patients. Manipulation of a total knee replacement with a notched anterior femoral cortex should probably be avoided.

A prospective study was done of the intermediate-term clinical and radiographic results of 121 total hip arthroplasties in which a Harris-Galante porous titanium-fiber-coated prosthesis was inserted without cement in 110 patients. The average age at the time of the operation was forty-nine years (range, twenty to seventy years). The average duration of follow-up was sixty-seven months (range, fifty-five to seventy-nine months). The average preoperative Harris hip score was 55 points, and the average postoperative score was 93 points. One acetabular component was revised due to recurrent dislocation. Eleven femoral implants were unstable, and of these, four were revised. Cortical erosion was present around the distal part of the femoral stem in nine patients (8 per cent) who had stable implants, and one of these femoral implants was revised because the erosion was extensive. Survivorship analysis at five years revealed a 97 per cent chance of survival (95 per cent confidence limit, 0.937 to 1.0) of the Harris-Galante femoral-stem implant inserted without cement.

Total hip arthroplasty with a special segmental replacement of the proximal end of the femur which varied in length from eighty to 150 millimeters was performed in twenty-one patients who had severe non-neoplastic conditions of the proximal part of the femur that necessitated salvage. Ten patients had previously failed arthroplasties associated with loss of bone structure; seven had non-union of a proximal femoral fracture or osteotomy associated with severe hip disease; there had a failed resection arthroplasty; and one had an arthrodesis and incapacitating low-back pain. Clinical and roentgenographic data during follow-up of twenty-five to ninety-two months showed that only one patient had loosening of the acetabular component. In twenty of the twenty-one patients, total hip arthroplasty with proximal femoral replacement was effective in restoring the integrity of the bone and restoring function of the hip.

We reviewed thirty-eight cases, in thirty-six patients, of fracture of the femur distal to the base of the neck incurred in conjunction with total hip replacement. There were thirteen preoperative, eighteen intraoperative, and seven postoperative fractures. The cases were contributed by thirteen surgeons. We found that the preoperative fractures with pre-existing disease in the hip joint were effectively treated by primary total hip replacement using custom-made femoral components with long necks or long stems, or both. The intraoperative femoral fractures usually occurred while the surgeon was reaming the canal, seating the femoral component, or manipulating the femur in patients who were predisposed to fracture. Theoretically these lesions can be treated like preoperative fractures, but this demands immediate access to custom-made femoral components with long necks or long stems, or both, along with an appreciation of the extent and significance of the fracture. Inadequate fixation was found to lead to painful non-union or late loosening of the femoral component in four of eighteen patients. Postoperative fractures occurred too rarely for us to draw any definite conclusions about management, except to say that surgical treatment can be hazardous and traction has been successful in this series and in other reports. Prophylactic measures, however, may help to prevent postoperative femoral fractures. Most of these fractures occur through a cortical defect near the tip of the femoral component. A long-stem femoral component may help to prevent postoperative fractures whenever a proximal cortical defect of the femur is present preoperatively or is created at surgery.