Periprosthetic and Peri-implant Fractures Clinical Presentation

Updated: Apr 04, 2023
  • Author: Steven I Rabin, MD, FAAOS; Chief Editor: Murali Poduval, MBBS, MS, DNB  more...
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By definition, all patients with a periprosthetic fracture will have a previous history either of joint replacement or of internal fixation for a fracture.  The term peri-implant fracture applies to periprosthetic fractures (ie, fractures around a joint replacement) while also including fractures around an orthopedic fixation device.

The patient's acute history will usually include a traumatic event (as with any nonperiprosthetic fracture) or may present more insidiously with gradual increasing pain secondary to a stress fracture around the implant. Intraoperative periprosthetic fractures may be the result of difficulty preparing for the placement of the implant (eg, overreaming the acetabulum before placing a total hip prosthesis) or difficulty placing the prosthesis (eg, a calcar fracture during implantation of the femoral component of a hip replacement when there is a mismatch between the size of the prosthesis and the area prepared for it).

Periprosthetic occult acetabular fractures are common during press-fit acetaular insertion in primary hip replacement and may not be recognized during surgery. Surgeons should have a high index of suspicion, especially in male patients who have unexplained early postoperative groin pain after cementless acetabular placement. [40]

A prefracture history of thigh pain with weightbearing or decreased mobility at the hip (for femoral periprosthetic fractures) predicts a high likelihood that the stem is loose. A periprosthetic fracture around an uncemented prosthesis that occurs within the first few weeks of implantation should be presumed loose because of insufficient time for the stem to become integrated. This diagnosis of a loose stem is important; it may not be apparent on imaging, but it is crucial in determining classification and best treatment. [5]


Physical Examination

The physical examination is essentially the same as for any fracture. Patients exhibit the usual signs of fracture and have a history of a previous prosthesis or implant. There is tenderness, swelling, and instability (usually) at the fracture site. There may be a limb-length discrepancy and deformity, and the patient may be unable to use the limb. The fracture can occur with minimal trauma (especially with a previously loose prosthesis or osteoporotic bone) or an obvious traumatic incident.

The examiner should check neurovascular status, evaluate for compartment syndrome, and identify any open wounds.