Prophylactic Cerclage: A Method of Preventing Femur Fracture in Uncemented Total Hip Arthroplasty

Abstract

The incidence of femur fracture in noncemented hip arthroplasty has been reported to be between 4.1 % and 27.8%. To quantitate the hoop stress generated during insertion of a femoral broach in total hip arthroplasty and determine the effect of cerclage with both braided cable and wire, we harvested 14 pairs of embalmed cadaver femurs. These were reamed and broached to duplicate the surgical technique of inserting a straight non-cemented femoral component. Group one consisted of eight matched cadaver femurs which were tested using a single 2.0 mm chrome-cobalt cable placed around the calcar of one femur, with the other serving as a control. Group two consisted of five matched cadaver femurs which were tested using a single 18 gauge cerclage wire in the same manner. In group one, the femurs serving as controls were found to have a mean microstrain of (1425.00 ± 1 180.19). The eight femurs tested with a 2 mm cable were determined to have a mean microstrain of (4179 + 2853.89). In group two, the femurs serving as controls were found to have a mean microstrain of (962.60 ±956.78). The five femurs in group two tested with a cerclage wire were determined to have a mean microstrain of (1112.00 ±975.66). Using a paired t-test, statistical significance was achieved with a confidence level of P=s.01 in group one. Prophylactic wiring of the proximal femur with 2 mm cable increases the hoop stress resistance and, therefore, should decrease the incidence of intraoperative femur fractures in uncemented total hip arthroplasty.

Risk Factors and Outcomes Associated with Intraoperative Fractures during Short-Stem Total Hip Arthroplasty for Osteonecrosis of the Femoral Head

“…Nwankwo et al 21) in their biomechanical study showed that the prophylactic cerclage of the proximal femur increases hoop resistance, decreases strain across bone during femoral broaching of THA, and plays a clinical role to reduce intraoperative fractures. Similarly, Herzwurm et al 22) and Waligora et al 23) in their cadaveric studies found prophylactic wiring increases not only hoop stress resistance to reduce intraoperative fractures during THA but also rotation and energy to failure in well-fixed press-fit femoral implants to minimize the risk of early periprosthetic fracture. Good radiological and functional outcomes in the present study advocate the use of prophylactic cerclage wiring in hips with poor bone stock as a viable option to offer bone-preserving benefits of short stems in young adults.…”

Femur Strength is Similar Before and After Iatrogenic Fracture During Total Hip Arthroplasty: A Biomechanical Analysis

“…Despite abundant innovations in implant design and surgical technique, iatrogenic periprosthetic fractures remain a key issue during primary THA affecting between 1.5% and 27.8% of cases [ [16] , [17] , [18] , [19] , [20] ]. It must also be acknowledged that, because many surgeons do not bill for repair of an iatrogenic periprosthetic fracture during primary THA, the true incidence may be higher [ 43 ].…”

“…During cementless THA, it is imperative that surgeons obtain initial mechanical stability of the femoral stem to reduce micromotion and increase bony fixation [ 15 , 16 ]. A known complication during femoral preparation is iatrogenic periprosthetic fracture, which is estimated to occur in 1.5%-27.8% of cases and is more common in uncemented THA [ [16] , [17] , [18] , [19] , [20] , [21] ]. Unrecognized iatrogenic fractures can propagate and decrease initial mechanical stability, [ 22 ] leading to early loosening and revision [ 17 , 22 , 23 ].…”

“…Prior studies have analyzed the relative efficacy of different fixation constructs in stabilizing iatrogenic periprosthetic fractures [ [34] , [35] , [36] , [37] ], as well as the potential risk reduction of sustaining such fractures with prophylactic cabling [ 20 , 38 ]. However, the ultimate strength of a femur with a tapered stem and cerclage wires after an iatrogenic periprosthetic fracture relative to the initial biomechanical strength of the same femur has not been described.…”

Extended Trochanteric Osteotomy with Intermediate Resection Arthroplasty Is Safe for Use in Two-Stage Revision Total Hip Arthroplasty for Infection

“…The potential concern of compromising infection eradication due to metallic hardware to fix the ETO fragment seems to play a negligible role, especially considering that cerclages are exchanged or removed at the time of reimplantation. The placement of a prophylactic cable distal to the ETO has been advocated for in an attempt to decrease the risk of intraoperative fracture during stem insertion [ 47 ]. In the underlying study, no intraoperative diaphyseal fracture was noticed regardless of the use of a prophylactic cable and all three postoperative fractures occurred in the non-ETO group.…”