Intraoperative Calcar Fractures in Uncemented Total Hip Replacement: A Systematic Review.

BACKGROUND

Intraoperative calcar fractures (IOCFs) are a recognized complication of uncemented total hip arthroplasty (THA), often occurring during femoral preparation or stem insertion due to the press-fit fixation required for cementless implants. The aim of this systematic review was to synthesize current evidence regarding the epidemiology, risk factors, management strategies, and outcomes associated with IOCFs in uncemented THA.

METHODS

A systematic search of electronic databases, including PubMed, MEDLINE, and Embase, was performed for studies reporting IOCFs during primary uncemented THA. Studies underwent 2 rounds of screening by 2 independent reviewers followed by data extraction and narrative synthesis. Risk-of-bias assessment was performed for each study.

RESULTS

Sixty studies were selected for inclusion in this systematic review, encompassing 465,030 primary uncemented THAs. The rate of IOCFs across all studies was 0.74% with reported incidences ranging from 0% to 10% for individual studies. Stem impaction was the most common step of the operation in which IOCF were sustained (72%). The most common fracture morphology reported involved extension until the lesser trochanter. Cerclage fixation was the most popular management strategy intraoperatively (>95%). Patient body mass index, use of smaller stems, procedures performed by trainees, and various aspects of femoral morphology were associated with significantly higher rates of IOCFs. At follow-up, patients managed for IOCFs showed minimal rates of complications including loosening of femoral components, need for revision surgery and stem subsidence.

CONCLUSION

IOCFs during uncemented THA are uncommon but clinically important complications. Prompt recognition and appropriate fixation, most commonly, with cerclage wiring generally result in favorable outcomes. Awareness of patient-related and procedure-related risk factors may help reduce the incidence of this complication and optimize intraoperative management.

LEVEL OF EVIDENCE: This review included studies ranging from between Level I to Level III evidence.