To the Editor:
I read with interest the article “Periprosthetic Femoral Fractures Associated With Hip Arthroplasty” ( http://www.orthosupersite.com/view.aspx?rid=78070) in the December 2010 issue of Orthopedics. The paper was well organized and well written. However, a specific entity is missing: iatrogenic intraoperative crack or fracture. This is a well-known entity that has been recognized since noncemented press-fit implants were introduced.
In our unpublished series, we estimated the occurrence of iatrogenic intraoperative fracture at approximately 1% to 2% as a rule at the calcar, but also at the borders of the greater trochanter. It was noticed more frequently in revisions, but was present in primary procedures as well. It is often taken care of by cerclage wire with or without cementing the stem. This entity is occasionally unrecognized and leads to postoperative pain or late propagation into fracture.
David G. Mendes, MD
We appreciate the interest in our review article. A discussion of iatrogenic and intraoperative periprosthetic fractures was intentionally deleted from early revisions of the article. In retrospect, omission of the topic entirely may have been an error. Our institutional experience is similar to that of Dr Mendes: iatrogenic and intraoperative fractures occur infrequently overall but are more common in revision situations and with the use of cementless implants.
Because of the increasing prevalence of total hip arthroplasty (THA) in our aging populations, the incidence of periprosthetic proximal femur fractures appears to be rising. These patients frequently present to small- and mid-sized hospitals after falling in their home. The orthopedic surgeon may have subspecialty interest outside of THA but may be experienced in the routine care of patients with fragility fractures. We recognize the benefit of treating geriatric patients close to their home and openly admit that transfer of all such patients for subspecialty care is not possible, particularly in the rural setting. Therefore, the intention of our article was to educate the on-call orthopedic surgeon to the unique needs of patients with periprosthetic proximal femur fracture. We intentionally omitted a discussion of the iatrogenic intraoperative fracture as the etiology, presentation, and treatment of intraoperative periprosthetic fracture is usually encountered by surgeons experienced in THA during or following elective hip surgery and is often unique to the surgical exposures and implants in use.
Thank you for identifying this omission for the Journal’s readers.
Zhiyong Hou, MD
Thomas R. Bowen, MD
Wade R. Smith, MD