AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Fractures around implants pose unique fixation challenges. The original placement of the implant may predispose to later fracture, the long-term presence of the device may change the structure of the bone and increase susceptibility to fracture, and the implant itself may interfere with healing or the placement of other fixation devices. The number of implants in the femur is increasing as the population ages, and the indications for joint replacement and fixation increase. Fractures around joint replacement prostheses are commonly called periprosthetic fractures, while fractures around plates, rods, or prostheses can be more generally termed peri-implant fractures. As more peri-implant fractures occur, the orthopedic surgeon needs to learn methods to manage the specific problems involved.

History of the Procedure

The number of orthopedic implants placed in the femur is increasing. More than 123,000 total hip and 150,000 total knee arthroplasties are completed each year in the United States, with the numbers expected to increase as the population ages (Rosenberg, 1996). The major complications of total joint arthroplasty are loosening and osteolysis. The rate of osteolysis increases with time, and osteolytic bone defects are stress risers, which predispose the patient to fractures.

More than 300,000 hip fractures occur yearly, and almost all are treated operatively with internal fixation or prosthetic replacement (Orthopedic Network News, 1997). Furthermore, the number of implants placed in other bones is increasing, with expanding indications for shoulder, elbow, and ankle replacement, and internal fixation continues to be used in all the long bones, especially the tibia and humerus.

Improvements in cancer treatment also have resulted in longer life spans with increased likelihood of metastatic bone lesions and impending or actual pathologic fractures that require internal fixation. The ability of tumor to "outgrow" a fixation device and the decreased ability of irradiated or tumor-replaced bone to heal fractures also results in an increasing frequency of peri-implant fractures.

Problem

As the number of implants placed increases, it is inevitable that associated fractures also become more common. Once a fracture occurs, treatment is complicated by osteoporosis (Figgie, 1990), defects in the bone, and the presence of the implant (Figgie, 1990; Sisto, 1985). Common problems include malalignment, stiffness, and nonunion (Sisto, 1985). If malalignment occurs after a periprosthetic fracture, the abnormal joint biomechanics may cause a high rate of revision secondary to loosening (Figgie, 1990).

The implant may impair fracture healing because of endosteal ischemia (Culp, 1987). Rates of nonunion for supracondylar fractures proximal to total knee prostheses are higher than for supracondylar fractures without the implant (Culp, 1987). Stems, rods, screws, and methylmethacrylate may block the medullary canal, preventing intramedullary fixation of fractures. Stems and rods also block screw fixation through the medullary canal to hold plates on bone. The techniques for treating peri-implant fractures may be more difficult, with more limited options and more frequent complications than the techniques used in treating fractures without the presence of an implant.

Frequency

The incidence of supracondylar fracture after total knee replacement is 0.6-2.5% (Culp, 1987; Figgie, 1990). Fracture can occur more than 10 years after joint replacement (Chmell, 1996); thus, as the number of patients with replacements accumulates, more fractures occur. The exact incidence and frequency of other peri-implant fractures has not been established.

Etiology

Peri-implant fractures can be caused by technical problems during their placement. Many studies have implicated notching of the anterior cortex of the femur during knee arthroplasty as the cause of supracondylar fracture (Culp, 1987), with a 40% fracture rate even 8 years after surgery (Figgie, 1990). However, other studies have questioned the association (Ritter, 1988). The calcar may fracture during hip arthroplasty (Fitzgerald, 1988; Shaw, 1994), the stem may penetrate the femoral shaft, or distal femoral fracture can occur with manipulation and preparation of the femur (Johansson, 1981; Shaw, 1994) (see Image 1).

Fractures can occur during internal fixation when screws are placed too close or bone holding devices crack the bone, especially in osteoporotic bone. Any drill hole up to 20% of the diameter of the bone weakens the bone by 40% of its original strength. Ninety percent of fractures around fracture fixation implants occur through a drill hole (Koval, 1994) (see Image 2). Displacement of unrecognized femoral neck fracture or new fracture occurs in 3% of intramedullary nailings of femoral shaft fractures (Wu, 1991; Azer, 1994). With any implant, the end of the device becomes a stress riser in which the weaker osteoporotic bone tends to fracture first when excessive load is applied (Koval, 1994).

Removal of devices is also associated with refracture. After plate removal, the cortical bone has been stress shielded and needs to be protected. Zickel intramedullary hip nails have been associated with subtrochanteric fracture when removed (Koval, 1994), and the more modern intramedullary hip screw systems may do the same. During prosthetic revisions, the rate of fracture is 17.6%, compared to 3.5% for primary procedures because osteoporotic bone or bone with osteolytic defects may fail while the prosthesis or its cement is being removed (Shaw, 1994).

Pathophysiology

Treatment of periprosthetic fractures requires strict adherence to the basic principles of treating any fracture. The surgeon must restore the biomechanical integrity of the bone. This requires restoration of a biologic environment in which the bone can heal and a mechanically stable construct to give the bone a chance to heal.

Biology is maintained by strict soft tissue and indirect reduction techniques, when possible, to preserve periosteal and/or endosteal blood supply. The surgeon should minimize periosteal stripping, avoid dead space, and consider bone grafting if the biological environment is compromised. The patient's medical condition should be optimized. The patient should be encouraged to stop smoking when applicable.

Mechanical stability is obtained by restoring the anatomic integrity of the bone and following Association for the Study of Internal Fixation (AO/ASIF) principles with adequate fixation distal and proximal to the fracture.

Clinical

Patients present with the usual signs of fracture with a history of previous prosthesis or implant. They have pain, deformity, swelling, possible limb length inequality, and inability 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.

INDICATIONS

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Essentially all periprosthetic fractures require some treatment. Stable nondisplaced fractures may only require protected weightbearing or cast/brace immobilization (and pain medication), but most unstable peri-implant fractures require surgical stabilization and/or implant replacement to restore function. Surgical intervention for peri-implant fractures follows the same guidelines as for other fractures. The goals of treatment include early ambulation, which helps avoid pulmonary complications, decubiti, disuse osteoporosis, and other complications of prolonged bedrest; restoration of axial alignment, which helps prevent eccentric stress on the prosthesis that leads to early loosening; and stabilization of the limb, which allows joint motion and helps prevent stiffness and muscle atrophy.

CONTRAINDICATIONS

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Treatment is rarely contraindicated after periprosthetic fracture. Observation of a fracture in a paralyzed limb may be indicated, but, even then, surgery is often useful to help with nursing care. Cancer patients with widespread resistant metastases also may be treated better with hospice or pain control alone. Patients with unstable medical conditions should be in optimal condition before surgery. If an associated infection exists, its treatment should be part of the surgical plan. Peri-implant fractures usually occur in elderly patients, and a team approach is often required for treatment.

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Lab Studies

• No special laboratory studies are required for most periprosthetic fractures. A sedimentation rate and CBC count with differential is useful if infection is suspected.

Imaging Studies

• Radiographs of the entire bone are required to assess the condition of the joint above and below the fracture, condition of the implant, presence of deformity or lesions that may influence surgical options, and axial alignment of the bone. Two views perpendicular to each other, most often an anteroposterior (AP) and lateral view of the bone, are always required.
• CT scan and MRI have limited use because of scatter artifact caused by the metallic implant. Bone scans are not specific.

Diagnostic Procedures

• Aspiration of a failed joint replacement may help if infection is suspected.

Histologic Findings

Biopsy at the time of surgery is indicated if pathologic fracture or infection is suspected.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Medical therapy

Casting, bracing, and protected weightbearing are indicated only for stable fractures in which the implant is not loose and alignment of the prosthesis and the limb both is acceptable for adequate function when the fracture heals.

Surgical therapy

Surgical options include replacement of the implant with a new implant, which also stabilizes the fracture, or fixation of the bone around the implant. Fixation options include intramedullary devices (rods, nails) or extramedullary devices (plates, screws).

Preoperative details

The most important factor in treating peri-implant fractures is the status of the implant. Careful assessment of preoperative x-rays and comparison with previous x-rays (when available) is essential.

When the implant is loose (Figgie, 1990; Shaw, 1994; Blaster, 1994), malaligned, or deformed, revision of the implant may be the best option. The potential difficulties of fixation and complications of nonunion or malunion are avoided by eliminating the fracture. Difficulties achieving fixation because the implant is in the way also are bypassed by removing the implant.

When the implant is not loose, its removal may be difficult, time consuming, and complicated by further fracturing of the bone or other complications of revision surgery. When the implant is stable and well aligned, the fracture usually can be treated with standard fixation methods while retaining the implant or prosthesis. An exception is when the bone stock for fracture stabilization is inadequate. If stable fracture fixation cannot be achieved, even if the implant is stable, the implant (or prosthesis) must be removed and joint replacement (or revision) is probably the best treatment.

Preoperative templating is required to ensure that adequate revision or fixation implants are available and the goals of surgery can be achieved. If screw fixation around a medullary stem or rod is planned, careful assessment of the implant's fit in the canal is necessary to ensure there will be room for the screws. Even unicortical screws require some space for their tip.

Intraoperative details

Treatment of peri-implant fractures by replacement of the implant

If the implant has failed, as in the case of a loose prosthetic replacement, the surgical treatment requires removal of the failed prosthesis and repeat replacement (revision) with a new prosthesis. The stem of the new prosthesis usually needs to be longer than the original so that it can bypass the fracture to stabilize it.

A case example of hip replacement after failed hip replacement is helpful. An 82-year-old woman with a preexisting loose hip replacement fell and sustained a periprosthetic femoral fracture (see Image 3). Radiographic evaluation showed moderately severe osteolysis with probable subsidence of the cemented femoral component (with a gap in the stem-cement interface at the lateral aspect of the prosthesis). Because the stem was loose, an acute revision operation with removal of the prosthesis, strut medial allograft, and long-stem femoral revision was performed. The acetabular component also was revised with an uncemented component because it was found to be loose at surgery. Postoperatively, the patient did well, with partial weightbearing for 3 months and a stable prosthesis with allograft incorporation at 6 months.

If the fracture cannot be stabilized, despite a stable implant, because of inadequate bone to hold fixation devices, surgical treatment can include removal of the implant and replacement of the inadequate bone with a new prosthesis.

In this case, a case example of hip replacement after fracture at tip of hip lag screw is helpful. An elderly man sustained an intertrochanteric hip fracture and was treated with dynamic hip screw implant. The original fracture healed, but he had a new fracture at the tip of the lag screw after a fall (see Image 4). Fixation options were few because of inadequate bone stock, and he had a good result with removal of hardware and hip hemiarthroplasty.

Treatment of peri-implant fractures by open reduction internal fixation

If fixation of the fracture is chosen instead of replacement, the usual principles of fracture fixation must be followed. Stable anatomic fixation with preservation of soft tissue attachments through indirect reduction techniques should be achieved to obtain good results (Culp, 1987; Koval, 1994). The surgeon must choose the device that fits the patient best with careful preoperative planning and intraoperative flexibility and creativity. A wide selection of implants must be available. Options include flexible intramedullary rods, rigid intramedullary rods, and special plates, possibly with cerclage wires.

Flexible intramedullary rods (eg, Zickel supracondylar, Ender, and Rush rods) can be slipped alongside intramedullary stems. They can be placed through minimal incisions and act as an internal splint until fracture healing occurs (Koval, 1994; Muller, 1991). They usually require some external protection (eg, cast, brace) and rarely allow unprotected motion or weightbearing. Preoperative radiographs must be studied carefully to be certain that there is enough room in the medullary canal for the implant. It may be difficult to maintain axial alignment and length with these devices. Their use mainly is indicated in patients in whom surgery is especially risky and the ability to place them with minimal surgical trauma outweighs the risk of imperfect reduction.

A case example of distal femur fracture with proximal hip replacement demonstrates this point. An elderly woman with a solid asymptomatic previous hip hemiarthroplasty fractured her distal femur in a fall. She was treated with Zickel supracondylar devices and healed without complication (see Image 5). At 3-year follow-up, the hip remains asymptomatic.

Rigid intramedullary rods (eg, antegrade, supracondylar, retrograde) are stronger than flexible rods and do not require external support. They cannot be used when a fracture has occurred around a stemmed implant (because the stem is in the way) but can provide rigid fixation for other peri-implant fractures. Advantages of intramedullary fixation include indirect reduction with less stripping of periosteal blood supply and preservation of soft tissues and the fracture hematoma with its bone forming cells and factors. Soft tissue protection increases the chance of union and decreases the chance of infection.

Biomechanically, the intramedullary position of the nail is stronger compared to plates because of increased resistance to torque forces and increased load transfer to the bone (Koval, 1994; Muller, 1991). A case example of a fracture at the end of a blade plate treated with a retrograde nail is as follows: A young man who fractured his hip in a high-speed motor vehicle accident less than 2 years ago refractured his femur at the distal end of his plate after another motor vehicle accident. Rigid fixation was obtained with retrograde rod (see Image 6).

The following is a case example of a fracture above a total knee replacement treated with an antegrade nail: An elderly woman with bilateral knee replacements sustained bilateral distal femur fractures proximal to her knee replacements. Rigid fixation and healing of both fractures was achieved with antegrade nailing (see Image 7).

A case example of pathologic fracture above a plate treated with an antegrade nail follows: An elderly woman with pathologic humerus lesion from metastatic breast cancer was treated initially with plate fixation that failed. Intramedullary fixation that was stable enough to restore function and decrease pain was required to improve quality of life (see Image 10).

Plates and screws are also commonly used to repair periprosthetic fractures. Although plates can be placed with indirect reduction techniques to minimize soft tissue damage and newer plate designs provide more "biologic" fixation (Muller, 1991), they usually destroy at least some of the periosteal blood supply and always disrupt the fracture hematoma. Plating techniques allow direct fracture reduction. This achieves more exact anatomic alignment, which may be crucial for long-term joint function (Koval, 1994).

Plating techniques allow for interfragmentary compression more readily. This creates a more rigid construct allowing early motion. Although intramedullary rods act as internal splints, plates can be placed as a tension band and/or neutralize the forces acting on interfragmentary screws (Muller, 1991). Special plates are usually required, allowing a combination of cerclage wires and screws to hold the plate to the bone while avoiding the intramedullary implant. Fractures of the calcar during hip replacement can be treated with cerclage wires or Parham bands (Fitzgerald, 1988).

A case example of a fracture at the distal end of a hip replacement treated with a plate is as follows: An elderly woman sustained a low-energy injury to her leg, with fracture occurring at the tip of a preexisting hip replacement. She had a solid hip arthroplasty; thus, open reduction internal fixation with plate, cerclage wires, and screws was performed. The fracture healed without evidence of prosthetic failure (see Image 8).

A case example of fracture at the proximal end of a supracondylar nail treated with a plate follows: An elderly woman with previous supracondylar femur fracture presented with a new fracture at the proximal tip of her supracondylar rod after a motor vehicle accident. Open reduction internal fixation with a plate was performed with a good result (see Image 9).

Newer fixed-angle locking unicortical screw plates now allow improved less invasive fixation than was allowed with older techniques, which used allografts and cerclage wires. Unicortical screws can be placed with far less periosteal stripping than cerclage wires. Mihalko and associates (1992) showed that cables can resist bending loads, but Schmotzer and associates (1996) demonstrated that cables resist torsional loads poorly compared to screws. The authors' cadaver research has shown that it takes 6 cerclage wires to equal the rotational and anteroposterior stability of a single unicortical screw with a lateral plate (Lohrbach, 2002.)

In a relevant case example, a 73-year-old man with periprosthetic femur fracture distal to a well-fixed total hip replacement stem presented with a nonunion after 3 attempts at plate fixation using cerclage wires for proximal fixation. Open reduction internal fixation was accomplished with 2 "combi" fixed-angle locking screw plates (anterior and lateral placement to help control both anterolateral and mediolateral forces) with healing within 3 months (see Image 11).

In another relevant case example, a 49-year-old woman with periprosthetic femur fracture 2 cm distal to a well-fixed total hip replacement stem presented with nonunion after 3 attempts at plate fixation using cerclage wires for proximal fixation and one attempt at retrograde rod fixation. Open reduction internal fixation was accomplished with a less invasive surgical stabilization (LISS) fixator and an anterior LC-DC plate. The anterior plate included a lag screw and the LISS was inserted using minimally invasive technique (including percutaneous proximal unicortical screw placement). She was clinically healed by 3 months and radiographically healed by 5 months (see Image 12).

Postoperative details

Postoperative care varies depending on the fracture, implant, method of fixation or replacement, quality of the bone, and ability of the patient to comply with instructions. In general, cemented prostheses and rigid intramedullary rods allow immediate weightbearing without casting or bracing. Uncemented prostheses often require protected weightbearing initially. Plate fixation and flexible intramedullary rods may require protected weightbearing and bracing or even casting. Physical or occupational therapy is often useful to maximize function.

Follow-up

The fracture should be monitored with radiographs and clinical examination until it heals. The patient should be monitored until rehabilitated to full potential. Prostheses should be checked yearly to detect early loosening or osteolysis.

COMPLICATIONS

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Complications are more common when treating periprosthetic fractures than when treating fractures without an implant. Surgery is technically more difficult, and bone quality is poorer. Increased operating time and increased blood loss are expected. Failure of fixation occurs when inadequate stability is achieved. Infection rates are increased because of increased soft tissue damage from more difficult surgical dissection. Deep venous thrombosis, pulmonary emboli, and systemic complications should be expected and treated early.

OUTCOME AND PROGNOSIS

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

A good outcome and prognosis is expected if the surgeon restores the biomechanical function of the limb. Failure to do so results in a poor outcome.

When treating periprosthetic fractures, the surgeon must evaluate the stability of the implant carefully. Loose implants used for fixation allow motion at the fracture site that interferes with healing and physically interferes with the placement of more stable fracture fixation. Loose prostheses used for joint replacement are painful and interfere with adequate fracture fixation. If the implant is loose or malaligned, the implant should be revised while the fracture is fixed at the same setting. If the implant is stable and sufficient bone stock is available for fracture stabilization, the implant should be retained while the fracture is fixed using standard treatment principles. When treating peri-implant fractures of the femur, the surgeon should have a flexible approach, using the best-fitting device, following basic fracture principles of rigid internal fixation and restoration of the anatomy and preservation of soft tissue attachments.

For optimal results when treating periprosthetic fractures, assess the stability of the fracture, restore mechanical stability, respect the biological environment, and have flexibility and choose the device that fits.

FUTURE AND CONTROVERSIES

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Current efforts to treat periprosthetic fractures focus on ways to avoid the fracture and new implants for improved fixation. New designs of replacement prostheses include changes in the shape of stems to better share load with the bone and avoid the osteoporosis of stress shielding, which weakens the bone and predisposes for fracture. New plate designs, such as the low contact dynamic compression plate, decrease the contact area of plates and decrease the osteoporosis of stress shielding. Changes in materials decrease bone destruction from osteolysis. Less rigid metals (eg, such as titanium vs stainless steel) share the load better. Fixed-angle plate systems (eg, LISS), allow more stable fixation with minimally invasive techniques (see Image 11).

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Media file 1:  Distal femur fracture during hip arthroplasty.
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Media file 2:  Failed fixation caused by fracture through screw holes.
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Media file 3:  Fracture around a loose prosthesis treated with replacement.
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Media file 4:  Fracture at the end of an implant treated with replacement.
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Media file 5:  Fracture around a stable prosthesis treated with flexible rods.
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Media file 6:  Fracture around a plate implant treated with rigid rod.
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Media file 7:  Fracture around a stable prosthesis treated with rigid rod.
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Media file 8:  Fracture around a stable prosthesis treated with standard plate.
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Media file 9:  Fracture around a stable rod implant treated with plate.
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Media file 10:  Fracture around a plate treated with a rod (pathologic).
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Media file 11:  Open reduction internal fixation with 2 combi fixed-angle locking screw plates (anterior and lateral placement to help control both anterolateral and mediolateral forces).
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Media file 12:  Fracture around a stable implant treated with a less invasive stabilization system (LISS) plate.
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REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

• Azer SN, Rankin EA. A complications of treatment of femoral shaft fractures. In: Epps CH, ed. Complications in Orthopaedic Surgery. 3rd ed. Philadelphia, Pa: JB Lippincott;1994:487-524.
• Blaster RB, Matthews LS. A Complications of Prosthetic Knee Arthroplasty in Complications. In: Epps CH, ed. Othopaedic Surgery. 3rd ed. Philadelphia, Pa: JB Lippincott;1994:1057-1088.
• Chmell MJ, Moran MC, Scott RD. Periarticular Fractures After Total Knee Arthroplasty: Principles ofManagement. J Am Acad Orthop Surg. Mar 1996;4(2):109-116. [Medline].
• Culp RW, Schmidt RG, Hanks G, et al. Supracondylar fracture of the femur following prosthetic knee arthroplasty. Clin Orthop. Sep 1987;(222):212-22. [Medline].
• Figgie MP, Goldberg VM, Figgie HE 3rd, et al. The results of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty. Sep 1990;5(3):267-76. [Medline].
• Fitzgerald RH Jr, Brindley GW, Kavanagh BF. The uncemented total hip arthroplasty. Intraoperative femoral fractures. Clin Orthop. Oct 1988;(235):61-6. [Medline].
• Johansson JE, McBroom R, Barrington TW, Hunter GA. Fracture of the ipsilateral femur in patients wih total hip replacement. J Bone Joint Surg Am. Dec 1981;63(9):1435-42. [Medline].
• Koval KJ, Frankel VH, Kummer F, Green S. A complications of fracture fixation devices. In: Epps CH, ed. Complications in Orthopaedic Surgery. 3rd ed. Philadelphia, Pa: JB Lippincott;1994:131-54.
• Lohrbach, Rabin S. Presented at the MidAmerica Orthopedic Association Annual Meeting. 2002.
• Mihalko WM, Beaudoin AJ, Cardea JA. Finite-element modelling of femoral shaft fracture fixation techniquespost total hip arthroplasty. J Biomech. May 1992;25(5):469-76. [Medline].
• Muller ME, Allgower M, Schneider R, Willenegger H. Manual of Internal Fixation. 3rd ed. New York, NY: Springer-Verlag;1991:1-112.
• Ritter MA, Faris PM, Keating EM. Anterior femoral notching and ipsilateral supracondylar femur fracture in total knee arthroplasty. J Arthroplasty. 1988;3(2):185-7. [Medline].
• Rosenberg AG, ed. A Total Hip Arthroplasty and A Total Knee Arthroplasty in Orthopaedic Knowledge Update 5. Rosemont, Ill:. American Academy of Orthopaedic Surgeons;1996:397,486.
• Schmotzer H, Tchejeyan GH, Dall DM. Surgical management of intra- and postoperative fractures of the femur about the tip of the stem in total hip arthroplasty. J Arthroplasty. Sep 1996;11(6):709-17. [Medline].
• Shaw JA, Greer RB III. A complications of total hip replacement in complications. In: Epps CH Jr, ed. Orthopaedic Surgery. 3rd ed. Philadelphia, Pa: JB Lippincott;1994:1013-1056.
• Sisto DJ, Lachiewicz PF, Insall JN. Treatment of supracondylar fractures following prosthetic arthroplasty of the knee. Clin Orthop. Jun 1985;(196):265-72. [Medline].
• Wu CC, Shih CH. Ipsilateral femoral neck and shaft fractures. Retrospective study of 33 cases. Acta Orthop Scand. Aug 1991;62(4):346-51. [Medline].

Article Last Updated: Mar 18, 2005