management_of_isolated_greater_trochanter.2

Review Article
Management of Isolated Greater Trochanter

Fractures Associated With Total Hip Arthroplasty
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Downloaded from http://journals.lww.com/jaaos by p3/5XE1TTAjoz84wfCgVYVDdg3bWrunUzMFkDdBkgqpKMTbgtTo
Andrew Fraval, MD
Erik M. Hegeman, MD
Chad A. Krueger, MD
ABSTRACT
Periprosthetic hip fractures are recognized complications associated
with total hip arthroplasty. Over the past decade, there has been a 2.5-
AMInr8HnDo4sCWQOKcok= on 05/25/2024
fold increase in the incidence of periprosthetic fractures which is

expected to grow exponentially in the future. Most of these fractures
require surgical fixation or revision arthroplasty. Fractures of the greater
trochanter represent a subset of periprosthetic fractures for which
there is currently no consensus in the literature regarding the optimal
management. The purpose of this review was to outline the
management strategies available to address these fractures, with
formulation of recommendations for fractures sustained
intraoperatively, postoperatively, and in the setting of primary and
revision total hip arthroplasty.
From the Rothman Orthopedic Institute at

Thomas Jefferson University (Fraval, and
T
he volume of total hip arthroplasty (THA) continues to grow with
Krueger), and Department of Orthopaedic
Surgery, San Antonio Military Medical Center models predicting a linear or even exponential growth into the near
(Hegeman). future.1,2 Accompanying the growth of primary and revision THAs
None of the following authors or any immediate performed will be the number of complications associated with these pro-
family member has received anything of value
from or has stock or stock options held in a
cedures. Reported rates of periprosthetic femoral fractures range from 0.8%
commercial company or institution related to 10% of all primary THAs.3,4 Abdel et al performed large retrospective
directly or indirectly to the subject of this article:
epidemiological studies on the complications associated with primary and
Fraval, Hegeman, and Krueger.
revision THAs over a 40-year period. Overall, the cumulative rate of peri-
This article does not contain any studies with
human participants or animals performed by any prosthetic fracture at 20 years was 3.5% in primary cases and 17.5% in the
of the authors. revision setting.5,6 Isolated fractures of the greater trochanter (GT) were
The views expressed in this article are those of found to be the most common type of periprosthetic fracture in the post-
the authors and do not reflect the official policy of operative period.5
the Department of Army, Defense Health Agency,
Department of Defense, or the US Government. The aim of this review was to provide a summary of the literature on how
A license for use was obtained for both figures 1a
best to manage isolated periprosthetic GT fractures. Malunion and displaced
and 1b of this manuscript by the British Editorial fractures may cause abductor insufficiency which may lead to persistent pain,
Society of Bone & Joint Surgery and Sage
weakness, instability, and a Trendelenburg gait. Yet, which patients are
Publishing respectively. License numbers are
1358563-1 and 5565690642082. bothered by these deficiencies and to what degree are difficult to predict.
J Am Acad Orthop Surg 2024;32:196-204 Furthermore, surgical management to alter the natural history of these out-
DOI: 10.5435/JAAOS-D-23-00560 comes is associated with high complication rates for loss of fixation, implant
Copyright 2023 by the American Academy of
prominence, and subsequent malunion with no consensus on appropriate
Orthopaedic Surgeons. management.7
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JAAOS® March 1, 2024, Vol 32, No 5 © American Academy of Orthopaedic Surgeons
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Andrew Fraval, MD, et al
Review Article
Vascular Considerations
Anatomy of the Greater Trochater The proximal femoral metaphysis has a robust vascular
The proximal femur is composed of three secondary supply with main contributions from both the medial and
ossification centers: the femoral head, GT, and lesser lateral circumflex femoral arteries. However, the GT is a
trochanter. The GT develops as a traction apophysis relative watershed area which relies on terminal arterial
with a secondary ossification center appearing at age 2 to branches and surrounding soft tissue for vascularization.
5 years.8 It serves as the insertion site for the hip ab- Churchill et al8 through angiography demonstrated that
ductors, external rotators, and origin of the vastus lat- most of the blood supply to the GT was extraosseous and
eralis. It has a unique blood supply which makes it the GT had a distinct blood supply from the femoral neck
prone to nonunion in the setting of fracture or oste- and shaft. Between these two circulations was a zone of
otomy. This discussion will focus on relevant anatomy relative avascularity in the area of the fused apophysis
which is pertinent in the setting of periprosthetic frac- with few intraosseous anastomoses (Figure 1, B). Given
tures and healing of GT fractures. that the supply to the GT relies heavily on extraosseous
blood supply, disruptions due to injury, surgical
Osseous Landmarks and Muscular approach, or femoral preparation may lead to decreased
Attachments perfusion of the GT and increase risk for fracture.
The osteology of the GT is complex and driven by its
muscular insertions (Figure 1, A). The lateral bony
surface of the GT provides insertion for the gluteus
medius and minimus and the origin for the vastus lat- Classification Schemes
eralis. The gluteus medius and minimus insert on the The Vancouver classification, introduced in 1995, was
proximal lateral aspect of the GT in a V configuration.9 the first comprehensive approach to classify peri-
The tip of the V extends inferiorly and lies close to the prosthetic hip fractures.10 It has postoperative and in-
vastus tubercle which is the origin site for the vastus traoperative schemes which allows for the pairing of
lateralis tendons.9 In addition, on the lateral aspect of radiographic findings to management strategies and has
the GT, there is an area devoid of tendon or fascial been validated by multiple studies.11,12
insertions termed the “bald spot” which is lies within The postoperative classification divides fractures
the V attachment point for the gluteus medius based on three principles: the location of the fracture, the
and minimus. The medial aspect of the GT includes the stability of the implant, and the quality of the sur-
insertion of the short external rotators with the conjoint rounding bone.10 Type A fractures are those that occur
tendon, piriformis, and obturator externus inserting above the level of the femoral prosthesis. GT fractures
anterior to posterior.9 are classified as “AG” fractures and distinct from “AL”
Figure 1
(A) Image showing the insertional anatomy of the greater trochanter from a posterior view by Philippon et al.9 (B) Image showing the
relative avascular zone of the greater trochanter seen with angiography by Churchill et al.8
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Management of Greater Trochanter Fractures in THA
fractures which involve the lesser trochanter. Intra- which have unique properties with respect to how they
operative fractures are classified by the fracture loca- behave clinically.
tion, pattern, and stability.13 Similar to the preoperative Based on the available intraoperative and postopera-
classification it divides fractures by location with type A tive classification schemes, fractures of the GT are not
being fractures involving the GT, type B if diaphyseal, appropriately subclassified to predict their behavior
and type C if distal to the tip of the implant. Each type is based on the deforming forces of the anatomic attach-
further classified into type 1 for cortical perforation, ments.14 We propose a new classification based on
type 2 for nondisplaced/stable, and type 3 for location of the fracture in relation to the GT insertional
displaced/unstable patterns. This classification, while anatomy (Table 1). This classification acknowledges the
providing clear guidelines for if a fracture is at the level important fracture variations observed due to the
or below the level of the prosthesis, falls short on sub- common deforming forces which will influence how the
classifying GT fracture patterns and morphologies fracture behaves in terms of displacement (Figure 2).
Table 1. Modified Greater Trochanter Fracture Classification

Anatomic Functional Treatment
Type Radiograph Description Significance Displacement Impairment Recommendation
1 Tip avulsion These are Unlikely, given Unlikely Observation with
fracture of fractures of the a lack of nonsurgical
the GT superomedial muscular protocols
rim of the attachments
greater
trochanter and
do not contain
notable muscle
attachment
2 Mid- The fracture Likely, due to Likely open reduction

substance line passes notable and internal
GT fracture between the unbalanced fixation (ORIF) or
gluteus deforming nonsurgical
medius/ forces in most management
minimus and cases (ORIF associated
vastus lateralis with high rates of
attachment nonunion)
sites
3 GT base This fracture Unlikely, given Unlikely Observation with

fracture line lies distal to the persistence nonsurgical
the vastus of some vastus protocols
insertion. The attachment to
fracture line the proximal
may often fracture
extend to fragment
shoulder of the
prosthesis
GT = greater trochanter
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Review Article
Figure 2 Revision Total Hip Arthroplasty Greater
Trochanter Fractures (Intraoperative and
Postoperative)
There is a paucity of adequate data regarding incidence
of GT fractures in the revision setting. In a large series of
5,417 revision THA cases, Abdel et al6 found that GT

fractures occurred in 20.4% of intraoperative and

28.1% of postoperative fractures identified. The
cumulative rate of GT fractures in this population was
3.2% (177/5,417). In complex primary and revision
THA with 2.5-year radiographic follow-up, Schafer
et al15 observed a cumulative rate of 3.9% (3/76),
however not differentiating intraoperative from post-
operative fractures.
Image showing the visual representation of the new Risk Factors

classification scheme.
Intraoperative
Numerous studies have performed statistical analysis on
After a review of the literature on periprosthetic GT the risk factors contributing to periprosthetic fractures;
fractures, this proposed classification system may have however, few focus specifically on GT fractures (Table
implication for union rates, persistent morbidity 2).16-20 Timing of these fractures intraoperatively are
associated with fracture nonunion, and may inform associated with femoral broaching and implant inser-
management strategies. tion; iatrogenic GT fractures in particular are at elevated
risk during these times.5 However, when evaluating
hybrid rasp-impaction broaching versus impaction
broaching neither technique has been shown to
Incidence decreased rates of GT fractures.19 The use of shorter
When considering the rates of GT fractures, emphasis stems maybe associated with lower rates of intra-
must be placed on defining the setting in which the operative GT fractures.20 Surgical approach likely
fracture occurred. This is important because these frac- contributes to the development of GT fractures with
tures have different characteristics, rates, risk factors, direct anterior (DA) approaches citing higher rates
and potential management strategies depending on (0.6% to 29%) compared with the posterior and lateral
based approaches because of the nature of femoral soft-
whether they occurred intraoperatively or postopera-
tissue releases, retractor placement, and femoral
tively in the primary or revision setting.
Primary Total Hip Arthroplasty Greater Table 2. Risk Factors for Intraoperative
Trochanter Fractures (Intraoperative and Periprosthetic Fractures
Postoperative)
Abdel et al performed large database reviews in both the Longer Stem Designs
primary and revision setting describing the epidemiol- Female sex
ogy of THA complications. Overall, GT fractures Lower Body Mass Index (BMI)
occurred in 0.8% (267) of their reported 32,644 pri- Osteoporosis (lower Dorr ratio)
mary cases.5 They note that in primary THA cases, GT Advanced age
fractures composed 24.7% of intraoperative fractures Hip dysplasia
and 32.1% of postoperative fractures identified. In the
Noncemented femoral stems
postoperative setting, this represented the most com-
Previous hip surgery
monly encountered periprosthetic fracture in their
Revision arthroplasty
series.
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Table 3. Risk Factors of Postoperative Periprosthetic sensus on the physical therapy or management protocols
Fractures to optimize nonsurgical clinical outcomes. The authors
of this article are of the view that because of the de-
Morbid Obesity
forming forces that may be exerted on the GT in
Smaller implant size
functional activities such as rising from sitting to
Cemented femoral components standing, it is unlikely that restricting mobility would

Polyethylene osteolysis have a protective effect on fracture fragment migration.

Given this, we provide patients with a gait aid to protect
against falls but provide no other restrictions in the
elevation for implant insertion.21 Hartford et al22
postoperative period. However, in the absence of clear
described a higher overall incidence of 2.2% (31) in
evidence to guide optimal recovery protocols, avoiding
their series of 1,401 patients using the DA approach
active abduction may be considered.
with 1.2% (17) occurring intraoperative and 1.0% (14)
seen postoperative. In similar cohorts using the DA
approach, Dietrich et al described an intraoperative GT Surgical
fracture rate of 2.5% (16) in 640 consecutive patients, Surgical management involves fixation of the GT frac-
and Foissey et al noted a rate of 2.4% (13) in 537 ture. Isolated fractures of the GT should not lead to stem
primary THAs.21,23 Contrary to this is a published series loosening and, therefore, rarely need femoral revision.
which found the incidence of GT fractures to be similar The fixation methods include cerclage cables, claw plates
when an anterior approach (3%) was used as compared (either using cable fixation, screw fixation, or a combi-
with an anterolateral approach (2.7%).14 nation of both), locking plates, tension bands, and suture
Furthermore, a report on a series of 440 total hip re- fixation. A recent systemic review concluded that the
placements using an anterolateral approach found 30 literature reporting on the outcomes of these various
GT fractures with an incidence of 6.8%.24 fixation options is heterogeneous, and no one fixation
method has proven superiority.7 Complication rates of
Postoperative surgical management were found to be 4% to 16% for
The risk factors for postoperative GT fracture and peri- nonunion, 3% to 18% for GT fragment migration, and
prosthetic fractures in general have been shown to be 5% to 24% for abductor weakness. Of note is the fact
different from those sustained intraoperatively (Table that this systemic review included fixation for GT os-
3).5 Hartford et al20 revealed through multivariable teotomies and fractures, with lower rates of failure of
analysis that morbid obesity and smaller implant size fixation in the setting of osteotomy as compared with
were factors that increased postoperative fracture risk. fracture.
In many cases, missed intraoperative fractures that
displace in the early postoperative period may explain Management of Greater Trochanter fractures
higher rates of postoperative fractures in the first Sustained Intraoperatively in the Setting of
3 months.20 In the late postoperative course, aseptic Primary Total Hip Arthroplasty
loosening and subsequent osteolysis of the GT cause Fractures sustained intraoperatively provide the surgeon
induce fracture and should be recognized as a risk with the option to address the fracture immediately with
factor.25 surgical fixation or leave the fracture to heal with non-
surgical measures. They may occur because of aggressive
retraction of the femur during acetabular preparation or
Management Options because of exposure and instrumentation of the femur.
Nonsurgical An assessment of the stability of the fracture could inform
Nonsurgical management usually involves a period of the need for fixation. A variety of reports provide out-
protected weight bearing while using an assistive device comes for fractures sustained intraoperatively. In an
for gait. Avoiding active hip abduction for 6 to 8 weeks early series by Pritchett et al,26 the authors reported on
to minimize the chance of displacement has also been outcomes of 11 fractures that occurred intraoperatively.
described.21 Contrary to this are reports where no re- Of these, six were seen at the time of surgery, and five
strictions are applied with patients who are able to were seen on the first postoperative radiograph. All
weight bear as tolerated and participate in normal fractures seen intraoperatively were managed with
postoperative protocols.22 Currently, there is no con- surgical fixation using a cable or suture repair. All
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Review Article
fractures seen postoperatively were managed without authors investigated fracture configuration and found
surgical fixation. No comparisons of these two groups that where the fracture occurred in the mid-substance of
were made by the author, and there was a low rate of the trochanter, patient reported outcome measures
persistent symptoms associated with the fracture; (PROMs) were worse, but no difference was seen if the
however, this was a descriptive analysis with limited fracture was managed operatively compared with
objective data to support these conclusions. The author nonoperatively. This correlates with type 2 fractures in
described the following indications for fixation. the classification system proposed by this article.
1. Dislocation or instability of the prosthesis A recent series reported the 2-year outcomes of pa-
2. Severe limp or pain tients with GT fractures sustained either intraoperatively
3. Widely displaced trochanter fracture .2 cm or in the early postoperative period managed with sur-
These indications have been commonly cited in subse- gical fixation.27 This series reported a nonunion rate of
quent reports on the management of GT fractures. Hart- 39%; however, for fractures when displacement was
ford et al22 reported on 17 fractures which occurred present before surgery, a nonunion rate of 77% was
intraoperatively, of which 13 were treated without fix- reported, suggesting that surgical fixation was an
ation and four were treated with fixation using cerclage unreliable method of achieving durable reduction and
wire. The decision for fixation was made by the surgeon subsequent union of the displaced fragment. For clinical
based on if the size of the fragment allowed for adequate outcomes, 32% patients had persistent pain over the
fixation. Overall, one radiographic nonunion occurred GT, 34% of patients were using an assistive ambulatory
where a fracture was treated with cerclage wire using a device, and 27% patients had alteration of their gait.
figure of the eight technique. In this case, the fracture size The use of an assistive ambulatory device was not sta-
was 20% of the GT. The average time to functional tistically different between patients who had a GT
healing was reported as 11 weeks; however, the details of nonunion versus union.
what this entailed were not forthcoming. There is no Intraoperative “chip” fractures, which correlate to
information reported to suggest that fractures managed type 1 fractures in the classification system outlined in
operatively had outcomes different from those managed this article, have been uniquely described as being
nonoperatively in this series; however, surgical manage- associated with the anterior approach.14 This relates to
ment was associated with a 25% chance of nonunion. the challenge of elevating the femur for instrumentation
Foissey et al21 reported on 13 isolated GT fractures through an anterior approach where the use of a
which likely occurred intraoperatively; although nine retractor over the posterior aspect of the GT may lead
were seen at the 2-month follow-up, only one was to a small proximal fracture. Given that these fractures
associated with a fall. Of these 13 fractures, two have minimal or no tendinous insertion and the size of
involved the entire GT and nine were partial fractures. the fracture is small, nonsurgical management has been
All fractures were managed nonoperatively with advocated to be the best course of action.
immediate full weight bearing. This resulted in a mean
Harris Hip Score (HHS) score of 98.5 at a minimum Management of Greater Trochanter Fractures
follow-up of 2 years with no Trendelenburg gait. The Sustained Postoperatively in the Setting of
two fractures involving the entire GT went on to Primary Total Hip Arthroplasty
asymptomatic nonunion. Postoperative fractures may occur either in the immedi-
Contrasting these reports of GT fractures ate postoperative setting, likely from an undiagnosed
causing minimal clinical effect is the publication by Brun intraoperative fracture, or in the delayed postoperative
et al14 who cited increased rates of poor clinical out- setting after a fall. Hartford et al21 reported on 14 iso-
comes. The authors of this study reported on 26 frac- lated GT fractures sustained postoperatively. Of these,
tures which were found to have markedly worse nine occurred within 1 week postoperatively without
EuroQol 5 Dimension score (EQ-5D), Oxford hip trauma and probably represent missed intraoperative
scores, and visual analog pain scores as compared with fractures. Postoperative trauma was the cause of frac-
compared with the expected outcomes reported in the ture in five patients postoperatively. None of the hips
hip registry of Sweden and New Zealand. The follow-up with postoperative fractures required return to the
duration of these patients was unclear; however, 65% operating room for surgical treatment. All healed with
reported limping postoperatively, and 46% reported an average displacement of 6 mm and no comparative
pain. There was no difference in outcomes if the fracture data was available to compare outcomes to patients
was fixed primarily, secondarily, or not fixed at all. The where no fracture occurred.
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In the series reported by Pritchett et al,26 19 fractures achieve union with no reported implant-related com-
occurred postoperatively, none of which were managed plications. There are no comparative studies comparing
with surgical fixation. Of them, six patients had a nonsurgical management and subsequent revision with
persistent limp and pain with displacement of the surgical fixation and revision, and both options have
fracture being 2 cm or greater. Of these six symptomatic support within the literature.
patients, three declined surgery and three underwent Management of GT nonunion in the setting of a hip
surgical fixation using a cable plate fixation method replacement presents a specific challenge in improving
with one subsequent failure of fixation. A recent sys- outcomes without exposing the patient to adverse events.
temic review of the management of isolated GT fractures An early series reported results from surgical fixation
not associated with a THA advocated for nonsurgical using a trochanteric claw plate in conjunction with
management, regardless of fragment displacement.28 wires.34 This series reported on 72 patients with union
Although the presence of a hip replacement presents in 70.8%, pain limiting their activity in 13.9%, plate
further consideration for stability and function of the removal in 5.5%, and persistent limp in 25% of pa-
prosthesis, these management principles may be applied tients. Similarly, a report by Laflamme et al35 described
to patients with postoperative acute fractures of the GT. the outcome of 15 patients with GT nonunion. They
Postoperative GT fractures may be associated with reported a favorable union rate of 87% with the use of
osteolysis in the setting of either metal or polyethylene dual locking plates but with plate removal being
debris. Furthermore, stress shielding associated with dis- required in 20% because of implant irritation. In this
tally fixed stems may occur, with minimal trauma or even series, patients with persistent nonunion had markedly
the force of muscular attachments subsequently leading worse Harris hip scores of 58 6 14 compared with
to a GT fracture. Because of the loss of bone stock, these patients where union occurred 77 6 12.8. Another
fractures present a particular challenge for attempting series reporting outcomes with the use of locking plates
surgical fixation, and as such several authors have rec- in the setting of GT nonunion reported on 15 fractures
ommended nonsurgical treatment. Claus et al29 reported managed with this technique and found a union rate of
on 9 GT fractures associated with osteolysis which were 92.3% with implant-related complications occurring in
all managed nonoperatively through a period of crutches 26.66%, which included both breakage and trochan-
and limited weight bearing for 4 to 6 weeks. They teric bursitis.36
reported only one nonunion in this series with six of the To our knowledge, there are no reports of outcomes
nine patients having no pain and normal gait. Another for trochanteric nonunion managed nonoperatively, nor
small series reporting on GT fractures in the setting of comparative reports comparing nonsurgical manage-
osteolysis recommend nonsurgical management, fol- ment with surgical management of established trochan-
lowed by revision surgery to address the underlying cause teric nonunion in the setting of THA. For symptomatic
of osteolysis where necessary.30,31 Contrary to this nonunion fractures that have failed surgical measures,
approach for management of these fractures is the report fragment excision has been described with mixed
by Wang et al32 who described the long-term results of results.37
wire fixation and allogeneic bone graft for patients with
GT fractures associated with osteolysis. They reported on Management of Greater Trochanter Fractures
19 fractures managed with this technique, 18 of which Associated With Revision Total Hip
healed at an average time of 5 months. All patients had Arthroplasty
revision of either their acetabular liner or acetabulum at GT fractures associated with revision surgery present an
the time of surgical fixation. additional challenge because they are often associated
In a series of 23 fractures associated with osteolysis, with poor bone stock, the need for complex prosthetic
Hsiegh et al33 managed 17 nonoperatively. Of these reconstruction, and a soft-tissue envelope affected by
fractures managed nonoperatively, 15 went on to previous surgery. Most of the literature on GT fractures
radiographic and clinical union after a period of 6 to in the setting of revision surgery report on outcomes
8 weeks of restricted activity and crutches. The re- associated with surgical fixation. Consideration for
maining two patients had displacement of their fracture bearing surfaces such as dual mobility or constrained
fragment, however remained asymptomatic. The re- liners should also be made given the effect of GT fractures
maining patients had internal fixation using bone on THA stability.
grafting and wire fixation in conjunction with revision High rates of nonunion and implant-related compli-
of worn components. All these patients were reported to cations have been described in this setting. In one series
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Review Article
reporting on 13 GT fractures associated with revision may consider managing these fractures either opera-
surgery, the use of a cable plate fixation construct re- tively or nonoperatively; however, no clear consensus in
sulted in a 38.5% nonunion rate and 28.6% implant the literature exists for guiding clinical decision making.
failure.38 In a large series reporting on 76 GT fractures
managed with surgical fixation using a cable plate, 30 of
these fractures were associated with revision surgery.15 Acknowledgments

This report did not separate results of fixation based on The authors thank Mr. William Vance for his exceptional
indication but reported a similarly high rate of nonunion medical illustrations.
and implant failure requiring revision surgery of 23.7%
and 36.8%, respectively.15 More favorable outcomes
were reported by Zarin et al39 who described 31 tro- References
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Review Article

Management of Isolated Greater Trochanter

fold increase in the incidence of periprosthetic fractures which is

From the Rothman Orthopedic Institute at

JAAOS® March 1, 2024, Vol 32, No 5 © American Academy of Orthopaedic Surgeons

JAAOS® March 1, 2024, Vol 32, No 5 © American Academy of Orthopaedic Surgeons

Table 1. Modified Greater Trochanter Fracture Classification

2 Mid- The fracture Likely, due to Likely open reduction

3 GT base This fracture Unlikely, given Unlikely Observation with

JAAOS® March 1, 2024, Vol 32, No 5 © American Academy of Orthopaedic Surgeons

5,417 revision THA cases, Abdel et al6 found that GT

fractures occurred in 20.4% of intraoperative and

Image showing the visual representation of the new Risk Factors

JAAOS® March 1, 2024, Vol 32, No 5 © American Academy of Orthopaedic Surgeons

Cemented femoral components standing, it is unlikely that restricting mobility would

Polyethylene osteolysis have a protective effect on fracture fragment migration.

JAAOS® March 1, 2024, Vol 32, No 5 © American Academy of Orthopaedic Surgeons

JAAOS® March 1, 2024, Vol 32, No 5 © American Academy of Orthopaedic Surgeons

JAAOS® March 1, 2024, Vol 32, No 5 © American Academy of Orthopaedic Surgeons

these fractures were associated with revision surgery.15 Acknowledgments

2. Kurtz S, Ong K, Lau E, Mowat F, Halpern M: Projections of primary and

JAAOS® March 1, 2024, Vol 32, No 5 © American Academy of Orthopaedic Surgeons

31. Regis D, Sandri A, Samaila E, Magnan B: Two-stage management of a

34. Hamadouche M, Zniber B, Dumaine V, Kerboull M, Courpied JP:

JAAOS® March 1, 2024, Vol 32, No 5 © American Academy of Orthopaedic Surgeons

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