Femoral neck fracture is a common short-term hip resurfacing failure mode, but later term fractures are starting to be reported. The fracture pattern may indicate whether etiology is primarily mechanical or biological Central 3mm thick coronal slices were cut from each of 50 cemented and 2 cementless fractured femoral components (27 males, 25 females). Fracture patterns were grouped as: “edge to edge”, “inside head”, “outside” and “edge to outside”1. Sections were decalcified and processed for routine histology to examine viability and remodelling. Bone viability was judged on the presence of osteocyte nuclei. Components were judged to be unseated if the cement mantle was more than twice the manufacturers recommended thickness. Histological and clinical data were correlated with fracture pattern. Overall average time to fracture was 6 months (1–85 months). There were 25 “edge to edge”, 12 “inside head”, 4 “outside” and 11 “edge to outside” fractures, which occurred after a median of 2.0, 13, 1.5, and 2.0 months respectively. The majority of the heads were viable, and the fractures occurred through a region of healing bone involving one or both edges. Fifteen heads with a substantial proximal avascular segment fractured at the interface between necrotic and viable bone, typically inside the component. Eleven implants (21%) were considered unseated. All 4 “outside” fractures were found to be unseated. All “inside head” fractures were seated, but 83% (10/12) of them were found to be avascular. The latest failure (85 months) occurred in association with wear-induced osteolysis. Both cementless components fractured early with an “edge to outside” pattern and were found to be substantially avascular. Avascular heads failed from one month to four years, usually inside the component. Viable heads tended to fracture early through an area of healing bone at or below the rim. Most fractures were technical failure-sand might be avoided with better patient selection and surgical technique.
