Is Surgical Approach for Primary Total Hip Arthroplasty Associated With Timing, Incidence, and Characteristics of Periprosthetic Femur Fractures?

Periprosthetic femur fractures (PFF) involving primary total hip arthroplasty (THA) remain a significant concern. The purpose of this study was to evaluate the effect of surgical approach during primary THA on early PFF with respect to fracture timing, incidence, radiographic parameters, and surgery-related factors. A retrospective review of all patients with PFF during or after primary THA from 2011 to 2019 was conducted at a single, urban academic institution. Of the study cohort of 11,915 patients, 79 patients with PFF were identified (0.66%). Direct anterior (DA), posterior anterior (PA), and laterally based (LA) cohorts were formed based on the surgical approach. PA and LA groups were combined to form a nonanterior (NA) cohort. Radiographic parameters, surgical factors, and fracture mechanism were analyzed. The incidence of fracture across approaches was 0.70% (33/4707; DA), 0.63% (35/5600; PA), and 0.68% (11/1608; LA) ( P  =.97). Time from THA to fracture was significantly shorter in the DA cohort (12.5 ± 14.1 days) than the NA cohort (48.2 ± 120.6 days) ( P  =.05). Postoperatively identified, atraumatic PFFs were more common in the DA cohort (78.3%, 18/23) than the NA cohort (51.6%, 16/31) ( P  =.045). There were no differences between groups in radiographic or other clinical parameters. Patients who underwent DA THA have significantly shorter time to PFF and were more often identified postoperatively with an atraumatic mechanism than patients who underwent NA approaches. The known difficulty in femoral exposure and stem placement with the DA approach may play a role in contributing to a higher rate of intraoperative or early postoperative PFF.