Three Differing Methods of Treating Intraoperative Non-Displaced Calcar Fractures Demonstrate Similar Radiographic Stem Subsidence

Background Several management strategies have been described to treat intraoperative calcar fractures during total hip arthroplasty (THA), including retaining the primary implant and utilizing cerclage cables or switching the implant to one that bypasses the fracture and achieves diaphyseal fixation. However, the radiographic and clinical outcomes of these differing strategies have never been described and compared. Methods We retrospectively identified 50 patients who sustained an intraoperative calcar fracture out of 9,129 primary THAs (0.55%) performed by one of three surgeons between 2008 and 2022. Each of the three surgeons consistently employed a distinct strategy for the management of these fractures: retention of the primary metaphyseal-engaging implant and placement of cerclage cables (CC), exchange to a modular, tapered-fluted stem (MTF), or exchange to a fully-coated, diaphyseal-engaging stem (FC). Stem subsidence was then evaluated on standing antero-posterior (AP) pelvis radiographs at three months and one year postoperatively. Postoperative medical and surgical complication rates were evaluated. Results A total of fifteen patients were treated with CC, 15 with MTF, and 20 with FC. At three-month follow-up, mean stem subsidence was 0.43 ± 0.08 mm, 1.47 ± 0.36 mm, and 0.68 ± 0.39 mm for CC, MTF, and FC cohorts, respectively (P = 0.323). At one-year, mean stem subsidence was 0.70 ± 0.08 mm, 1.74 ± 0.69 mm, and 1.88 ± 0.90 mm for the CC, MTF, and FC cohorts, respectively (P = 0.485). Medical complications included 2 venous thromboembolic events (VTEs) (4%) within 90 days of surgery. There were 6 reoperations (12%); 3 (6%) for acute periprosthetic joint infection (all within the FC cohort); 2 (4%) for postoperative periprosthetic fractures (one fracture distal to the stem in the FC cohort and one fracture at the level of the stem in the MTF cohort), and 1 (2%) closed reduction for instability (within the CC cohort). Discussion The three described methods of managing intraoperative non-displaced calcar fractures demonstrated little radiographic stem subsidence, however, the risk of reoperation was much higher than expected.