Larger femoral periprosthetic bone mineral density decrease following total hip arthroplasty for femoral neck fracture than for osteoarthritis: a prospective, observational cohort study

Increased Rates of Late Periprosthetic Fractures in Larger Hydroxyapatite-Coated Cementless Stems: Are Collared Stems a Better Alternative for Total Hip Arthroplasty?

BACKGROUND

Cementless hip stems are widely used for total hip arthroplasty (THA) and have demonstrated excellent survivorship. This study aimed to investigate the effects of stem size and calcar collars on rates of revision due to periprosthetic fracture.

METHODS

All primary THA procedures recorded by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from September 1999 to December 2021 for a diagnosis of osteoarthritis using a single cementless hip stem with modern bearings were included. The primary outcome measure was revision due to periprosthetic fracture. Stems were divided into 2 groups for comparison, large (size 14 to 20) and small-medium (6 to 13). A subanalysis was performed for collared stems. A total of 59,518 primary THA procedures were included.

RESULTS

The cumulative percent revision for periprosthetic fracture was significantly higher for large stems compared to small-medium stems (hazard ratio [HR] = 1.57 [95% confidence interval {CI} 1.18, 2.09] P = .002). Furthermore, collared stems had significantly lower revision rates due to late periprosthetic fracture compared to collarless variants (2 week + HR = 4.55 [95% CI 3.23, 6.42], P < .001). Large collarless stems were found to have greater revision rates due to fracture compared to small-medium collarless stems (HR = 1.55 [95% CI 1.13, 2.12] P = .006), but no difference was found between collared groups (HR = 1.37 [95% CI 0.68, 2.78] P = .382).

CONCLUSION

Large cementless hip stems have a higher rate of revision due to periprosthetic fracture compared to small-medium stems. Using a collared stem reduces the rate of periprosthetic fracture.

Impact of Hepatitis B virus infection on postoperative complications and length of stay in elderly patients with hip fracture: A retrospective cohort study

BACKGROUND

Osteoporosis and subsequent fractures are common in the chronic hepatitis B (CHB) population, especially in the elderly. This study investigated the effects of hepatitis B virus (HBV) infection on postoperative outcomes following hip fracture surgery.

METHODS

The study identified elderly patients who underwent hip fracture surgery at three academic tertiary care centres between January 2014 and December 2020. Propensity score matching was performed to compare the outcomes of 1,046 patients with HBV infection to 1,046 controls.

RESULTS

The seroprevalence of HBV among elderly patients undergoing hip surgery was 4.94%. The HBV cohort had significantly higher rates of medical complications (28.1 vs. 22.7%, p = 0.005), surgical complications (14.0 vs. 9.7%, p = 0.003), and unplanned readmissions (18.9 vs. 14.5%, p = 0.03) within 90 days of surgery. Patients with HBV infection were more likely to have increased length of stay (6.2 vs. 5.9 days, p = 0.009) and in-hospital charges (¥52,231 vs. ¥49,832, p < 0.00001). Multivariate logistic regression suggested that liver fibrosis and thrombocytopenia were independent risk factors for major complications and extended LOS.

CONCLUSION

Patients with HBV infection were at greater risk of adverse postoperative outcomes. We should pay more attention to the considerable burden of perioperative management of CHB patients. Due to the high proportion of undiagnosed patients in the Chinese elderly population, universal HBV screening should be considered preoperatively.

A Review of Total Hip Arthroplasty Comparison in FNF and OA Patients

BACKGROUND

Worldwide, total hip arthroplasty (THA) has become one of the most commonly performed surgical procedures. Femoral neck fracture (FNF) and osteoarthritis (OA) are two of the medical conditions necessitating a hip replacement, most frequently carried out. The preoperative and postoperative pathways for patients suffering from these two diseases differ, yet worldwide, many national healthcare systems underestimate or misinterpret the (more than nuanced) care plan differences of the two. Factors and Criteria. Analyzed material was gathered from studies published between 2013 and 2019. Various strands of data demographics, comorbidities, and complications, as well as treatment outcomes, were tabulated to compare and contrast THA patients suffering from FNF and OA to collate their findings. Outcomes were cross-checked and validated for reliability and then were presented in a table format.

RESULTS

All five retrospective cohort studies fitted the required criteria for inclusion in this work, four US-based study groups and one European-based study group. Data were gathered from three separate databases. The "average" FNF patient is 76.8 years old. There was a 68.96% female probability. The "average" OA patient is 69.15 years old. There was a 5.24% female probability. 59.57% operated for athrosis, and only 34.63% operated for fracture which received grade lower than the third in the American Society of Anaesthesiologist (ASA) classification. There was more than 3 times higher prevalence of complications in the trauma group. FNF patients' hospitalization was approximately 3 days longer. On average, 3.7% of patients operated for trauma and 1.5% of patients with elective THA required a second surgery. 6.57% FNF and 2.93% OA patients had unplanned readmission.

CONCLUSIONS

In general, patients who suffer a femoral neck fracture are an extremely fragile group. They require additional perioperative and postoperative care. To meet these desired expectations, more FNF cost-comprehensive systems need to be initiated.

Factors affecting the incidence of postoperative periprosthetic fractures following primary and revision hip arthroplasty: a systematic review and meta-analysis

Objectives

The increasing number of hip arthroplasties (HA), due to the growing elderly population, is associated with the risk of femoral periprosthetic fractures (FPFs). The purpose of this study was to identify potential risk factors for the development of FPFs after HA.

Methods

A systematic review was conducted in five data bases (Medline, Embase, Cochrane, Cinahl, ICTRP) according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines up to May 2019, using the key words “risk factor,” “periprosthetic fracture,” and “hip replacement or arthroplasty.” Meta-analysis of the clinical outcomes of HA and subgroup analysis based on the factors that were implicated in FPFs was performed.

Results

Sixteen studies were included (sample size: 599,551 HA patients, 4253 FPFs, incidence 0.71%). Risk factors statistically associated with increased incidence of FPFs were female gender (+ 40%), previous revision arthroplasty surgery (× 3 times), and the presence of rheumatoid arthritis (× 2.1 times), while osteoarthritis (− 57%), cement application (− 59%), and insertion of Biomet (− 68%) or Thompson’s prosthesis (− 75%) were correlated with low prevalence of FPFs. Obesity, cardiac diseases, advanced age, bad general health (ASA grade ≥ 3), and use of Exeter or Lubinus prosthesis were not linked to the appearance of FPFs.

Conclusion

This meta-analysis suggested that female gender, rheumatoid arthritis, and revision arthroplasty are major risk factors for the development of FPFs after a HA. In those patients, frequent follow-ups should be planned. Further prospective studies are necessary to clarify all the risk factors contributing to the appearance of FPFs after HA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-020-02152-0.

Union rate, complication rate, and opioid usage after Vancouver B periprosthetic femur fractures: a comparison of fracture types

INTRODUCTION

Periprosthetic femur fractures are complex injuries that can be difficult to treat and recover from. With a growing number of total hip arthroplasties (THA) and revision arthroplasties being performed in an aging population, the incidence of these injuries is on the rise. Multiple studies exist detailing outcomes associated with periprosthetic femur fractures after THA, but no study has directly compared the post-operative course between fracture types as classified by the Vancouver classification system. This study compares the three Vancouver B fracture types to see if any type is associated with an increase in post-operative complications than others.

MATERIALS AND METHODS

This retrospective chart review was conducted at a suburban orthopedic surgery department. Overall, 122 patients who presented to our hospital with periprosthetic proximal femur fractures after hip arthroplasty over the past 13 years were reviewed. Patients were included if they underwent surgical stabilization of their femur fracture. Patients were excluded if they underwent non-operative treatment or had missing chart information. For each patient, demographic information, fracture information, surgical information, post-operative course, and post-operative opioid usage were recorded and compared among groups.

RESULTS

Overall, 88 fractures were included. Fifty-five (62.5%) were Vancouver type B1, 27 (30.7%) were Vancouver type B2, and 6 (6.8%) were Vancouver type B3. Most of our patients were female (n = 62, 70.5%) and older than 81 years of age (n = 53, 60.2%) with uncemented prosthesis (n = 83, 94.3%). All three fracture groups had statistically similar union rates (p = 0.77), infection rates (p = 0.32), subsequent fractures (p = 0.63), repeat surgeries (p = 0.64), and post-operative opioid use (measured in milli-morphine equivalents) after surgical stabilization (p = 0.96).

CONCLUSIONS

While periprosthetic femur fractures after hip arthroplasty are associated with high complication rates and poor outcomes, there is no difference in union rate, infection rate, subsequent fractures, repeat surgery rate, and opioid usage between the different Vancouver B fracture types.

LEVEL OF EVIDENCE

Prognostic level III.

Perioperative patient-specific factors-based nomograms predict short-term periprosthetic bone loss after total hip arthroplasty

BACKGROUND

Although medical intervention of periprosthetic bone loss in the immediate postoperative period was recommended, not all the patients experienced periprosthetic bone loss after total hip arthroplasty (THA). Prediction tools that enrolled all potential risk factors to calculate an individualized prediction of postoperative periprosthetic bone loss were strongly needed for clinical decision-making.

METHODS

Data of the patients who underwent primary unilateral cementless THA between April 2015 and October 2017 in our center were retrospectively collected. Candidate variables included demographic data and bone mineral density (BMD) in spine, hip, and periprosthetic regions that measured 1 week after THA. Outcomes of interest included the risk of postoperative periprosthetic bone loss in Gruen zone 1, 7, and total zones in the 1st postoperative year. Nomograms were presented based on multiple logistic regressions via R language. One thousand Bootstraps were used for internal validation.

RESULTS

Five hundred sixty-three patients met the inclusion criteria were enrolled, and the final analysis was performed in 427 patients (195 male and 232 female) after the exclusion. The mean BMD of Gruen zone 1, 7, and total were decreased by 4.1%, 6.4%, and 1.7% at the 1st year after THA, respectively. 61.1% of the patients (261/427) experienced bone loss in Gruen zone 1 at the 1st postoperative year, while there were 58.1% (248/427) in Gruen zone 7 and 63.0% (269/427) in Gruen zone total. Bias-corrected C-index for risk of postoperative bone loss in Gruen zone 1, 7, and total zones in the 1st postoperative year were 0.700, 0.785, and 0.696, respectively. The most highly influential factors for the postoperative periprosthetic bone loss were primary diagnosis and BMD in the corresponding Gruen zones at the baseline.

CONCLUSIONS

To the best of our knowledge, our study represented the first time to use the nomograms in estimating the risk of postoperative periprosthetic bone loss with adequate predictive discrimination and calibration. Those predictive models would help surgeons to identify high-risk patients who may benefit from anti-bone-resorptive treatment in the early postoperative period effectively. It is also beneficial for patients, as they can choose the treatment options based on a reasonable expectation following surgery.

Bone Loss Following Cementless Hemiarthroplasty for the Treatment of Femoral Neck Fracture

BACKGROUND

With the advances in medicine, an increasing number of the ageing population are a public health concern in terms of age-related complications. Among them, displaced neck fractures often require surgical intervention or arthroplasty to achieve the mobilization of the elderly and good life quality. The aim of the study is to monitor the changes in bone mineral density (BMD) around the femoral stem and the effects on functional outcomes in patients treated with cementless hemiarthroplasty following femoral neck fracture.

MATERIALS AND METHODS

Seventy-one patients aged 70 years or older who were treated with cementless hemiarthroplasty for a displaced femoral neck fracture were prospectively followed for 2 years. The percent change in the periprosthetic BMD in each Gruen zone was compared to the baseline using dual-energy X-ray absorptiometry (DEXA). Demographic factors [age, body mass index (BMI), and sex] that could possibly influence BMD and the clinical outcome were evaluated.

RESULTS

Fifty-one patients were available for the final follow-up. The mean age was 76.5 (range 70-89) years. The mean BMI was 28.9 (range 22.7-37.2). The mean Harris hip score at the final follow-up was 84.3 (range 72-93). There was a significant decrease in BMD in all Gruen zones (p < 0.001), except in zone 3 (R3, p = 0.547). The reduction in BMD was highest in the calcar and the greater trochanter region. The femur diaphysis was relatively spared, with zone 3 showing no significant bone mineral loss. The age and BMI of the patients were not correlated with the postoperative change in BMD in any of the Gruen zones. The degree of reduction in bone density was not correlated with the clinical outcome.

CONCLUSIONS

Cementless hemiarthroplasty for the treatment of femoral neck fracture in elderly patients achieves a good clinical outcome despite significant bone loss around the femoral stem. The reduction in BMD is more pronounced in the metaphyseal region.

A Review on Bone Mineral Density Loss in Total Knee Replacements Leading to Increased Fracture Risk

The link between low bone mineral density (BMD) scores leading to greater fracture risk is well established in the literature; what is not fully understood is the impact of total knee replacements/revisions or arthroplasties on BMD levels. This literature review attempts to answer this question. Several different databases using specific key terms were searched, with additional papers retrieved via bibliographic review. Based on the available evidence, total knee replacements/revisions and arthroplasties lower BMD and thus increase fracture risk. This review also addresses the possible implications of this research and possible options to reduce this risk.

Histological study of atraumatic periprosthetic fractures: does atypical periprosthetic fracture exist?

Purpose

Is it possible a correlation between some periprosthetic femoral fractures and atypical fractures?

Case

We present a case of a 77-year-old woman with atypical periprosthetic femoral fracture. The patient had a history of long-term bisphosphonate use. We performed an open reduction, a synthesis of the fracture and a histological exam. The patient stopped the bisphosphonate (BF) therapy. Three months later, before starting the teriparatide treatment, the patient had a re-fracture so we did a second osteosynthesis and began a teriparatide therapy. After six months, the radiography showed a bone healing at the fracture site.

Result

The histological examination confirmed the diagnosis of atypical femoral fracture.

Conclusion

At first, the fracture showed a delayed union which led to a new surgery, as often happens in BF-related atypical fractures. Appropriate treatment (BF suspension and teriparatide beginning) permitted fracture healing. The atypical characteristic of the fracture was confirmed by histological exam.Some periprosthetic femoral fractures in patients treated with BF, especially in long time therapies, should be suspected as atypical fractures and a specific medical treatment should be performed, as well as a correct surgical treatment.

Teriparatide Versus Alendronate for the Preservation of Bone Mineral Density After Total Hip Arthroplasty - A randomized Controlled Trial

In this study, the effect of teriparatide for the prevention of bone mineral density (BMD) loss after THA was compared with alendronate in a randomized controlled trial. Forty-eight patients were assigned to three groups, namely, the teriparatide, alendronate, and no medication groups. Dual-energy x-ray absorptiometry (DEXA) was performed at 1 week post-surgery as a baseline reference, followed by subsequent measurements at 12, 24, and 48 weeks postoperatively. For periprosthetic BMD loss, a significant effect of teriparatide was demonstrated, though its effect was similar to alendronate. On the other hand, higher lumbar BMD was observed in the teriparatide group than in the alendronate group at 48 weeks post-surgery. Teriparatide administration may be one reasonable option for osteoporotic patient to preserve the periprosthetic BMD after THA.