High prevalence and undertreatment of osteoporosis in elderly patients undergoing total hip arthroplasty

Patients with periprosthetic femoral fractures are older adults who are commonly diagnosed with osteoporosis

This study focused on individuals aged ≥ 50 years with periprosthetic femoral fractures (PFF). When compared to those with native hip fractures, patients with PFF were older, had a higher BMI, and demonstrated a greater number of comorbidities. Given the high frequency of osteoporosis risk factors and the BMD results, PFF should be classified as osteoporotic fractures.

INTRODUCTION

To compare patients presenting with periprosthetic femoral fractures (PFF) to patients with native hip fractures with a special focus on bone mineral density (BMD) measurements, in order to reinforce the hypothesis that PFF are osteoporotic fractures.

METHODS

A retrospective, single-centre, observational study of all patients aged ≥ 50 years with low-energy PFF identified at the Lille University Hospital from January 1, 2016, to December 31, 2022, was conducted. The PFF group was compared to a group of patients with native hip fractures hospitalized during the same period. To compare the T-score data, we used a linear mixed model that considered a predefined adjustment for age, sex, and BMI. Adjusted means ± standard error of the mean (SEM) are derived from the mixed model.

RESULTS

Among 71 patients with PFF (78.9% female, median (IQR) age 81 (72-88) years), osteoarthritis (57.8%) was the primary indication for hip surgery. Compared with the native hip fracture group (n = 117), patients in the PFF group were significantly older (p = 0.002), had a significantly greater BMI (p = 0.043), and had a higher history of multiple falls (54.3% vs. 26.1%, p < 0.001). A greater frequency of previous low-energy fractures (69.0% vs. 44.0%, p < 0.001) and an increased prescription of anti-osteoporosis medications (26.8% vs. 11.1%, p = 0.006) in patients with PFF were found. Adjusted T-scores differed between the two groups at the lumbar spine (mean adjusted ± SEM, - 0.5 ± 0.2 (PFF group) vs. - 1.2 ± 0.2 (comparator group), p = 0.008) but not at the femoral neck or at the total hip.

CONCLUSION

Low-energy PFF should be considered as an osteoporotic fracture and treated accordingly.

Preoperative Osteoporosis Is Associated With Increased Health Care Utilization and Compromised Pain and Function Improvement After Primary Total Hip Arthroplasty: A Prospective Cohort Analysis

BACKGROUND

Osteoporosis (OP) has been linked to complications after total hip arthroplasty (THA), but its impact on health care utilization and patient-reported outcomes remains unclear. This study aimed to evaluate the association between: 1) pre-THA OP and health care utilization as well as patient-reported pain and function outcome measures; and 2) dual energy X-ray absorptiometry (DEXA) scan-based T-scores and the aforementioned outcomes.

METHODS

A retrospective analysis of prospectively collected data of primary THA (2015 to 2018) was performed (n = 5,321) from a validated academic institutional database of a large North American tertiary health care system; of which 4,074 (76.6%) completed 1-year follow-up. Outcomes included prolonged length of stay [LOS] > three days, discharge disposition, 90-day readmission, and 1-year reoperation, as well as Hip Disability and Osteoarthritis Outcome Score (HOOS]) Pain, HOOS-function (PS), and minimal clinically important difference thresholds (MCID), and satisfaction.

RESULTS

The prevalence of OP pre-THA was 56.9%, of which 39.8% were not prescribed OP medications and 15.3% had a DEXA scan. Compared to those who did not have OP, those who had OP were independently associated with higher odds of prolonged LOS, nonhome discharge, 90-day readmission, and 1-year reoperation (P < 0.005). Furthermore, they had significantly higher odds of failing to achieve MCID (odds ratio: 1.41 (95% confidence interval: 1.06 to 1.89)) for HOOS-PS and satisfaction (odds ratio: 1.5 (95% confidence interval: 1.16 to 1.93)) at one year. Higher T-scores were associated with lower odds of prolonged LOS, nonhome discharge, failure to achieve MCID in HOOS-Pain, and HOOS-PS.

CONCLUSIONS

Over half of patients had OP; however, only 15.3% of patients had a DEXA scan before THA. Patients who had OP were at higher risk of prolonged LOS, nonhome discharge, 90-day readmission, and 1-year reoperation in addition to poor pain/function improvement and dissatisfaction one year after THA.

Trabecular titanium acetabular cup in patients with medial femoral neck fracture: Survivorship analysis and clinical and radiological outcomes

BACKGROUND

Clinical studies using Trabecular Titanium™ acetabular cups have shown promising short and medium-term results. This material, due to its macro and micro surface roughness, provides a substrate for osseointegration and enhances implant stability. However, there is a lack of evidence in the literature on the use of this material in patients with femoral neck fracture.

AIM

To evaluate the short-term clinical-functional and radiographic outcomes in patients with femoral neck fractures undergoing total hip arthroplasty (THA) with Trabecular Titanium™ acetabular cup implants.

METHODS

The study included 104 patients with medial femoral neck fractures who underwent THA between January 2020 and December 2020 with the Delta TT acetabular cup (Lima Corporate, Villanova di San Daniele del Friuli, Italy). The mean age of the patients was 69.57 ± 10.16 years (range: 36-85 years). The follow-up period ranged from a minimum of 3 to a maximum of 4 years. Three questionnaires (Harris Hip Score, Oxford Hip Score, and EQ5D) were administered along with radiographic evaluations. Statistical methods included the Student's t-test and one-way analysis of variance for comparisons (with significance set at 0.05), and the Kaplan-Meier curve for prosthetic implant survival.

RESULTS

The mean follow-up was 41.5 months. The Harris Hip Score (HHS) showed a mean increase of 2.74 points (mean HHS 88.52 at 6 months postoperatively and mean HHS 91.26 at the last follow-up) with statistical significance. Similarly, the Oxford Hip Score demonstrated a statistically significant difference between follow-up groups. However, the EQ5D did not show statistically significant differences among the three groups (preoperative, 6-month follow-up, and last follow-up). Revision surgery was required in 6 patients. According to Moore's criteria, 96% of the acetabular components were radiographically stable and well-integrated at the last follow-up. The Kaplan-Meier curve showed a 96% survival rate.

CONCLUSION

The clinical and radiographic results obtained in the short to medium term confirm the excellent performance of the Delta TT acetabular cup in terms of osseointegration, providing an optimal solution both for young patients with high functional recovery demands and for fragile patients requiring optimal stability of the acetabular component to reduce the risk of implant failure.

Osteoporosis screening using X-ray assessment and osteoporosis self-assessment tool for Asians in hip surgery patients

OBJECTIVES

As many patients with osteoporosis remain undiagnosed, we aimed to develop a simple method to efficiently screen for osteoporosis using a combination of anteroposterior hip X-ray assessment and the Osteoporosis Self-Assessment Tool for Asians (OSTA), which is calculated as (body weight - age) × 0.2.

METHODS

One hundred Japanese women (age: 73 ± 11 years, body weight: 54.4 ± 11.1 kg) who underwent hip surgery, anteroposterior hip X-ray, and DXA were included. Based on the DXA results of the total proximal femur, 35 cases were diagnosed with osteoporosis. Fifteen orthopaedic surgeons visually inspected the hip X-ray images and scored the suspicion of osteoporosis on a scale of 1-4 (1: very unlikely, 4: very suspicious), which is referred to as "pred-score." In addition, OSTA was calculated as a continuous variable (OSTA score). Osteoporosis was screened using the pred-score and OSTA score, and both scores were analyzed using the receiver operating characteristic curves.

RESULTS

The area under the curves (AUCs) of the pred-score and OSTA score were 0.626-0.875 and 0.817 across surgeons, respectively. When both scores were used, the AUC for screening osteoporosis ranged from 0.821 to 0.915 across surgeons. Significant improvement from AUCs calculated with the pred-score or OSTA score was found in 11 surgeons (73.3%).

CONCLUSION

The combination of X-ray assessment and OSTA can be used to screen for osteoporosis and has the potential to be used as a new simple screening tool in daily clinical practice.

Evidence-based joint statement position of perioperative bone optimization in the arthroplasty candidate, from FEMECOT, AMMOM, ACOMM, SCCOT, SECOT, SEFRAOS, SEIOMM

BACKGROUND

The prevalence of patients living with joint replacements is increasing. Nearly two-thirds of patients undergoing elective arthroplasty procedures have low bone mineral density (LBMD), defined as osteopenia in 38.5% and osteoporosis in 24.8%; among those with osteoporosis, only 32.8% received treatment at the time of surgery.

MATERIALS AND METHODS

A group of 7 national societies (FEMECOT, AMMOM, ACOMM, SCCOT, SECOT, SEFRAOS, SEIOMM) developed a joint statement position on the diagnosis of osteoporosis and perioperative bone optimization in candidates for arthroplasty "Arthroplasty Bone Optimization." We performed a scoping review of the available literature, followed by a systematic review and meta-analysis. Subsequently, a Delphi-modified method was used to gather the different positions.

RESULTS

After analyzing the literature, we came up with five recommendations: (1) Patients scheduled for elective arthroplasty should undergo a bone health assessment (BHA). (2) If poor bone quality is observed during surgery and a bone health assessment has not been conducted promptly, a complete BHA, including a DXA scan, is imperative. (3) In the arthroplasty candidate, if LBMD or osteoporosis are noticed, bone loss-related factors should be corrected, and appropriate treatment for osteoporosis should be started before or right after arthroplasty. The use of anti-resorptive and bone anabolic agents has been shown to reduce periprosthetic bone loss, complications, and non-septic revision rates after joint arthroplasty. (4) In arthroplasty candidates, the diagnosis of osteoporosis or low bone mineral density (LBMD) should not delay the surgery. (5) Monitoring central and periprosthetic bone mineral density through DXA protocols can help identify bone loss in central and periprosthetic areas in patients with risk factors or osteoporosis.

CONCLUSIONS

Perioperative bone optimization should be considered in all patients who are candidates for arthroplasty. The orthopedic surgeon and multidisciplinary team should be encouraged to diagnose and treat the arthroplasty candidates' bone by screening for bone loss-related factors and diagnosing osteoporosis and starting treatment according to the current international guidelines. Following these recommendations could reduce periprosthetic bone loss, complications, and aseptic revision rates following arthroplasty surgery. More research is needed to understand the implications of osteoporosis and its treatment for joint replacement outcomes and long-term survival.

Lee's TRIAD-osteoporosis, fragility fracture, and bone health optimization

Osteoporosis, fragility fractures, and bone health optimization share the same pathophysiology, diagnostic tools, risk assessment, and treatments. Grouping them into "Lee's TRIAD" allows surgeons and physicians to collaborate more efficiently, using unified principles and strategies for managing these conditions.

PURPOSE

The primary goal of osteoporosis management is to prevent fragility fractures, which occur from falls from standing height or less in individuals over fifty. However, the management of bone health optimization is often neglected in patients undergoing elective surgeries, such as arthroplasty and spinal surgeries. The objective of this article is to link all these three conditions into a TRIAD so that surgeons and physicians can collaborate more effectively, utilizing similar principles and strategies for better management.

METHODOLOGY

Clinical approaches based on country-specific guidelines are commonly used to manage osteoporosis. However, skeletal assessments are rarely conducted before or after elective procedures, leading to overlooked conditions such as osteoporosis, osteopenia, and fragility fracture risk factors. These three conditions are illustrated from the patient case study shown, to highlight the importance of not neglecting bone health optimization in high risk individuals undergoing elective surgery, with underlying osteopenia and multiple risk factors who sustained fragility fracture intraoperatively.

RESULT

Patients undergoing elective surgeries often have their bone health neglected, leading to a higher incidence of complications such as aseptic loosening and peri-prosthetic fractures due to poor bone quality and density. Bone health assessment and optimization therefore is essential in patients with osteoporosis, osteopenia with clinical risk factors, and patients with history of fragility fracture, to ensure implants sit on bone with good density and quality to minimize the complications.

CONCLUSION

By combining osteoporosis, fragility fractures, and bone health optimization into a TRIAD, "Lee's TRIAD," surgeons and physicians can collaborate more effectively, utilizing similar principles and strategies for better management.

[Risk factors and prevention strategies for periprosthetic femoral fractures in hip arthroplasty]

BACKGROUND

Periprosthetic fractures represent a major complication following joint replacement surgery, particularly total hip arthroplasty (THA). Due to demographic changes, a rising number of THAs is expected to lead to an increase in periprosthetic femoral fractures (PPF) in the coming decades. Despite the resulting high clinical relevance, there is as yet no comprehensive overview of risk factors and possible preventive approaches to PPF.

OBJECTIVES

The aim of this review is to present current findings and data from various studies and to derive evidence-based recommendations for clinical practice.

METHODS

Narrative review.

RESULTS

Various factors, such as advanced age, female sex, and rheumatic conditions, can increase the risk of PPF. In the presence of risk factors, a comprehensive assessment of bone health, including DXA osteodensitometry, should be considered prior to surgery.

CONCLUSIONS

An individualized approach is essential in the planning and execution of THAs to minimize the risk of PPF. In cases of confirmed osteoporosis or for women aged ≥ 70 years and men aged ≥ 75 years, cemented stem fixation should be chosen, as uncemented stems are associated with an increased risk of PPF. Overall, the clinical risk profile should be considered in preoperative planning and postoperative care to reduce this complication and improve patient care.

Total Hip Arthroplasty in Patients with Hip Osteoporosis: A Narrative Review

Osteoporosis and osteopenia can affect patients undergoing arthroplasty of the hip, which is typically recommended for patients with severe osteoarthritis or elderly patients with a femoral neck fracture. Preoperative screening for this type of bone loss could be helpful to patients and prevent poor outcomes due to the rate of underdiagnosis of osteoporosis, which can reach 73% in patients undergoing hip arthroplasty. Complications associated with low bone mineral density include periprosthetic fractures as well as an increased revision rate. Although the benefit of antiresorptive medications postoperatively has been demonstrated, when administered preoperatively, worse outcomes were reported compared to its non-usage. Surgical management is as important as pre-medication. According to general recommendations, cemented implants provide greater benefit in osteoporotic patients. However, when using cementless implants, ribbed stems, straight tapered stems, stems with medial calcar contact, and titanium-composed stems can be used to prevent periprosthetic loss of bone mineral density; however, they should not be placed in a varus position. These stems can also be coated with zoledronate and other products.

Sex-Specific Association of Clinical Parameters and Components of Femoral Bone Quality in Patients Undergoing Total Hip Arthroplasty

Poor bone quality is a critical factor associated with an increased risk of complications after total hip arthroplasty (THA). However, no consistent recommendations have yet been established for assessing indicators of bone quality preoperatively. Thus, it remains unclear which preoperatively available and readily accessible parameters are most closely associated with femoral bone quality. Here, we obtained femoral neck specimens from 50 patients undergoing THA. Preoperative Dual-energy X-ray absorptiometry (DXA) scans, pelvic radiographs, and laboratory parameters were analyzed. In the obtained specimens, bone microstructure was assessed using micro-CT and histomorphometry. Additionally, matrix mineralization and osteocyte lacunar morphology were evaluated using quantitative backscattered electron imaging. Our analysis revealed that DXA-derived T-scores correlated with trabecular microstructure. Furthermore, radiographic indices and body mass index correlated differentially with aspects of bone quality in women and men. Contrary to previous observations, no correlation was found between serum vitamin D levels and osteoid indices, nor between clinical parameters and matrix mineralization. Age was strongly associated with the number of mineralized osteocyte lacunae, a factor that appeared to be independent of sex. Taken together, our study demonstrates that no single preoperatively available parameter exhibits a strong and consistent association with femoral bone quality. However, DXA remains a reliable preoperative measure for determining the trabecular microstructure of the femoral neck. In clinical practice, surgeons should adopt an individualized approach to preoperative assessments by considering age, sex, BMI, and radiographic indices to enhance their insight into femoral bone quality, particularly when DXA is unavailable.

Systemic Osteoporosis and Osteopenia Among Periprosthetic Fractures After Total Hip Arthroplasty

BACKGROUND

Most periprosthetic fractures following total hip arthroplasty (THA) are fragility fractures that qualify patients for osteoporosis diagnoses. However, it remains unknown how many patients were diagnosed who had osteoporosis before injury or received the proper evaluation, diagnosis, and treatment after injury.

METHODS

We identified 171 Vancouver B2 (109) and B3 (62) periprosthetic femur fractures treated with a modular fluted tapered stem from 2000 to 2018 at 1 institution. The mean patient age was 75 years (range, 35 to 94), 50% were women, and the mean body mass index was 29 (range, 17 to 60). We identified patients who had osteoporosis or osteopenia diagnoses, a fracture risk assessment tool (FRAX), bone mineral density (BMD) testing, an endocrinology consult, and osteoporosis medications. Age-appropriate BMD testing was defined as no later than 1 year after the recommended ages of 65 (women) or 70 years (men). The mean follow-up was 11 years (range, 4 to 21).

RESULTS

Falls from standing height caused 94% of fractures and thus, by definition, qualified as osteoporosis-defining events. The prevalence of osteoporosis diagnosis increased from 20% before periprosthetic fracture to 39% after (P < .001). The prevalence of osteopenia diagnosis increased from 13% before the fracture to 24% after (P < .001). The prevalence of either diagnosis increased from 24% before fracture to 44% after (P < .001). No patients had documented FRAX scores before fracture, and only 2% had scores after. The prevalence of BMD testing was 21% before fracture and 22% after (P = .88). By the end of the final follow-up, only 16% had received age-appropriate BMD testing. The proportion of patients who had endocrinology consults increased from 6% before the fracture to 25% after (P < .001). The proportion on bisphosphonate therapy was 19% before fracture and 25% after (P = .08).

CONCLUSIONS

Although most periprosthetic fractures following THA are fragility fractures that qualify patients for osteoporosis diagnoses, there remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment. Like nonarthroplasty fragility fractures, a systematic approach is needed after periprosthetic fractures.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Durability of Primary Total Hip Arthroplasty With Cementless Stems Without a Collar in Elderly Patients Age 75 Years and Over

BACKGROUND

Cementless femoral fixation in total hip arthroplasty (THA) has increased in prevalence worldwide. However, cementless fixation in elderly patients is controversial due to the risks of periprosthetic fracture and aseptic loosening. This study evaluated outcomes in patients undergoing primary THA utilizing a cementless stem without a collar, comparing those less than 75 years to those older than 75 years.

METHODS

Between 2011 and 2021, there were 2,605 cementless THAs performed by 4 surgeons utilizing a highly porous metal fixation surface without a collar and consistent clinical protocols. There were 469 patients who had an age ≥ 75 years. Revision rates, intraoperative fractures, and 90-day mortality were compared between cohorts. In the ≥ 75 year age group, there were more women, more American Society of Anesthesiologists physical status classification III or IV, a lower body mass index, and more kidney disease, osteoporosis, and thyroid disease (P ≤ .002).

RESULTS

All-cause revision rates trended lower for the ≥75 year age group compared to < 75 year (1.9 versus 3.5%, P = .082) at 20-months of follow-up. Moreover, there was no difference in all-cause femoral component revisions comparing ≥ 75 to < 75 year age groups (1.5 versus 2.2%, P = .375), with only 3 of 10 femoral revisions due to aseptic loosening being in the ≥ 75 year age group. Intraoperative fracture (0.2 versus 0.5%, P = .701) and 90-day mortality (0.2 versus 0.1%, P = .460) did not differ between ≥ 75 and < 75 year age groups.

CONCLUSIONS

Older patients had comparable revision rates compared to younger patients using cementless femoral fixation without a collar. Furthermore, there was no difference in 90-day mortality or intraoperative fracture rates. Study findings provide evidence for the safety and durability of cementless THA using collarless femoral stems in elderly patients ≥ 75 years of age.

LEVEL OF EVIDENCE

III.

Usage of Tranexamic Acid for Total Hip Arthroplasty: A Matched Cohort Analysis of 144,344 Patients

Background: The literature is inconclusive regarding the potential complications of tranexamic acid (TXA), an antifibrinolytic drug, for total hip arthroplasty (THA). The purpose of this study is to compare complication rates and patient outcomes between THA patients administered TXA vs. THA patients not administered TXA. Methods: The TriNetX Research network was utilized to generate a cohort of adult patients who underwent THA between 2003 and 2024. These patients were categorized into two subgroups for the retrospective analysis: (1) patients who received TXA 24 h prior to THA (TXA), and (2) patients who did not receive TXA 24 h prior to total hip arthroplasty (no-TXA). The follow-up period was 30 and 90 days. Results: At 30 days following THA, the TXA patients had a reduced risk of transfusion (risk ratio (RR): 0.412; 95% confidence intervals (CI): 0.374, 0.453), reduced risk of DVT (RR: 0.856; CI: 0.768, 0.953), reduced risk of joint infection (RR: 0.808; CI: 0.710, 0.920), but a higher rate of periprosthetic fracture (RR: 1.234; CI: 1.065, 1.429) compared to patients who did not receive TXA. At 90 days following THA, TXA patients had a reduced risk of transfusion (RR: 0.446; CI: 0.408, 0.487), DVT (RR: 0.847; CI: 0.776, 0.924), and periprosthetic joint infection (RR: 0.894; CI: 0.815, 0.982) compared to patients who did not receive TXA. Patients who received TXA had higher rates of periprosthetic fracture (RR: 1.219; CI: 1.088, 1.365), acute postoperative anemia (RR: 1.222; CI: 1.171, 1.276), deep surgical site infection (SSI) (RR: 1.706; CI: 1.117, 2.605), and superficial SSI (RR: 1.950; CI: 1.567, 2.428) compared to patients who did not receive TXA. Conclusions: Patients receiving TXA prior to THA exhibited significantly reduced the prevalence of blood transfusions, DVT, and periprosthetic joint infection following THA. However, superficial SSI and periprosthetic fracture were seen with higher rates in the TXA cohort than in the no-TXA cohort.

Patients with Periprosthetic Femoral Hip Fractures are Commonly Classified as Having Osteoporosis Based on DXA Measurements

Periprosthetic femoral hip fractures are subject to an increasing incidence and are often considered to be related to osteoporosis. However, there are no available studies that have determined the frequency of osteoporosis in affected patients using gold standard dual-energy X-ray absorptiometry (DXA). In this retrospective comparative study, we analyzed the DXA results of 40 patients with periprosthetic femoral hip fractures who were treated surgically in our department. DXA measurements were performed at the total hip and the lumbar spine to determine bone mineral density T-scores. Data were compared to two age-, sex-, and BMI-matched control groups in which patients underwent DXA prior to aseptic revision surgery for other causes or primary THA (consisting of 40 patients each). The mean T-score in the periprosthetic fracture cohort was significantly lower (- 1.78 ± 1.78) than that of the aseptic revision (- 0.65 ± 1.58, mean difference - 1.13 [95% CI - 1.88 to - 0.37]; p = 0.001) and the primary THA cohort (- 0.77 ± 1.34, mean difference - 1.01 [95% CI - 1.77 to - 0.26]; p = 0.005). Accordingly, osteoporosis was detected more frequently (45%) in the fracture cohort compared to patients undergoing aseptic revision (12.5%) and primary THA (10%). In conclusion, almost half of the patients with periprosthetic femoral hip fractures have osteoporosis according to DXA measurements. A regular assessment of bone health in THA enables identification of patients with osteoporosis who likely benefit from initiation of osteoporosis medication and cemented stem fixation.

Patients with Osteoporosis Are at Higher Risk for Periprosthetic Femoral Fractures and Aseptic Loosening Following Total Hip Arthroplasty

This report provides an updated analysis for patients with osteoporosis following total hip arthroplasty (THA). The comorbidities of alcohol abuse, chronic kidney disease, cerebrovascular disease, obesity, and rheumatoid arthritis continue to be significant risk factors for periprosthetic femur fracture (PPFFx) and aseptic loosening in the population with osteoporosis. Patients with dual-energy x-ray absorptiometric (DEXA) scans were at risk for PPFFx regardless of femoral fixation method, and patients with DEXA scans with cementless fixation were at risk of aseptic loosening after THA. The patient population with severe osteoporosis may have higher risks for aseptic loosening and PPFFx than previously recognized.

The cementless taper wedge vs. fit-and-fill stem in primary total hip arthroplasty: risk of stem-related complication differs across Dorr types

INTRODUCTION

The choice between a cementless taper wedge stem and a fit-and-fill stem in total Hip arthroplasty (THA) for various proximal femoral morphological types has not been thoroughly evaluated. This study aimed to compare the risk of stem-related complications between these two stem types in Dorr type A, B, and C femurs.

MATERIALS AND METHODS

From January 2015 through April 2021, we retrospectively reviewed 1995 cementless THA procedures. We stratified all procedures into three groups: Dorr type A (N = 360, 18.0%), B (N = 1489, 74.7%) and C (N = 146, 7.3%). The primary outcome domain was stem-related complications, including stem subsidence ≥ 3 mm, intraoperative fracture, periprosthetic fracture and aseptic stem loosening. We performed multivariate regression analysis to compare the risk of stem-related complication between the two stem types. Other factors included age, sex, body mass index, diagnosis, age-adjusted Charlson comorbidity index, stem alignment and canal fill ratio.

RESULTS

The incidence of stem-related complications in the taper wedge and fit-and-fill stem groups was 4.4% (N = 15) and 6.5% (N = 107), respectively. Fit-and-fill stems showed an increased risk of stem-related complications (aOR: 9.903, 95% CI: 1.567-62.597) only in Dorr type C femurs. No significant difference in risk was observed in Dorr type A and B femurs. Furthermore, the canal fill ratio at the lesser trochanter, 2 cm and 7 cm below the lesser trochanter, did not exhibit an association with stem-related complications in any Dorr type.

CONCLUSIONS

Concerning the risk of stem-related complications, the taper wedge stem was a better choice in Dorr type C femurs. However, there was no difference in risk between the taper wedge stem and fit-and-fill stem in Dorr type A and B femurs.

Osteoporotic Patients Undergoing Total Hip Arthroplasty Have a Similar 5-Year Cumulative Incidence Rate of Periprosthetic Fracture Regardless of Cemented Versus Cementless Femoral Stem Fixation

BACKGROUND

In osteoporotic patients, surgeons may utilize cemented femoral fixation to minimize risk of fracture. The purpose of this study was to compare 5-year implant survivability in patients who have osteoporosis who underwent elective total hip arthroplasty (THA) with cementless versus cemented fixation.

METHODS

A retrospective analysis of patients who have osteoporosis undergoing THA with either cemented or cementless femoral fixation was conducted using a national administrative claims database. Of the 18,431 identified THA patients who have osteoporosis, 15,867 (86.1%) underwent cementless fixation. The primary outcome was a comparison of the 5-year cumulative incidences of aseptic revision, mechanical loosening, and periprosthetic fracture (PPF). Kaplan-Meier and Multivariable Cox Proportional Hazard Ratio analyses were used, controlling for femoral fixation method, age, sex, a comorbidity scale, use of osteoporosis medication, and important comorbidity.

RESULTS

There was no difference in aseptic revision (Hazard's Ratio (HR): 1.13; 95% Confidence Interval (CI): 0.79 to 1.62; P value: .500) and PPF (HR: 0.96; 95% CI: 0.64 to 1.44; P value: .858) within 5 years of THA between fixation cohorts. However, patients who had cemented fixation were more likely to suffer mechanical loosening with 5 years post-THA (HR: 1.79; 95% CI: 1.17 to 2.71; P-value: .007).

CONCLUSIONS

We found a similar 5-year rate of PPF when comparing patients who underwent cementless versus cemented femoral fixation for elective THA regardless of preoperative diagnosis of osteoporosis. While existing registry data support the use of cemented fixation in elderly patients, a more thorough understanding of the interplay between age, osteoporosis, and implant design is needed to delineate in whom cemented fixation is most warranted for PPF prevention.

Bone evaluation study-2: update on the epidemiology of osteoporosis in Germany

Osteoporosis is the most common bone disorder. Our data gives an estimate of around 5.87 million cases of osteoporosis in the general German population in 2018. Only 30% of insured individuals who suffered an osteoporotic fracture and/or had a confirmed diagnosis of osteoporosis, received an appropriate prescription.

PURPOSE

Osteoporosis is the most common bone disorder. It particularly affects elderly people and increases the risk of atraumatic fractures. The aim of this study was to estimate the prevalence of osteoporosis in the general German population aged ≥ 50 years and to collect data on the frequency of prescription of osteoporosis-specific medication in order to assess the treatment gap.

METHODS

Retrospective analysis of anonymized data of individuals aged ≥ 50 years insured under statutory healthcare schemes from the database of the Institute for Applied Health Research Berlin (InGef) for 2018 (study population). Insured individuals with osteoporosis were identified based on osteoporosis diagnoses, osteoporosis-specific prescriptions, or osteoporotic fractures. Thus, we estimated the prevalence of osteoporosis in the general German population aged ≥ 50 years. The prevalence of diagnoses, fractures, and prescriptions was determined for the study population and stratified by age and gender.

RESULTS

Within the study population of 1,599,299 insured individuals, a prevalence of osteoporosis of 15.9% was determined. This estimated approximately 5.87 million cases of osteoporosis for the general German population. 81.6% of the cases were women. Osteoporosis-specific prescriptions were received by 30.0% of the insured individuals in the study population who had been diagnosed with osteoporosis and/or suffered an osteoporotic fracture.

CONCLUSIONS

Germany has a high prevalence of osteoporosis. Only a small portion of individuals who may require osteoporosis-specific treatment actually receive it.

A prospective and consecutive study assessing short-term clinical and radiographic outcomes of Chinese domestically manufactured 3D printing trabecular titanium acetabular cup for primary total hip arthroplasty: evaluation of 236 cases

Purpose

We prospectively evaluate the short-term clinical and radiographic outcomes of the only Chinese domestically produced trabecular titanium acetabular cup(3D ACT™ cup) in primary total hip arthroplasty (THA), aiming to provide evidence-based support for its clinical application.

Methods

A total of 236 patients, who underwent primary THA using 3D ACT™ cup in the Department of Joint Surgery at our hospital between January 2017 and June 2019, were included in this study. General patient data, imaging information, functional scores, and complications were collected to evaluate the early clinical efficacy.

Results

All patients were followed up for 33-52 months, with an average of (42.2 ± 9.2) months. At the last follow-up, the preoperative HHS score increased significantly from 43.7 ± 6.8 to 85.6 ± 9.3 points (P < 0.01). Similarly, the preoperative WOMAC scores showed significant improvement from 59.2 ± 5.8 to 13.1 ± 3.5 points (P < 0.01). 92.3% of the patients expressed satisfaction or high satisfaction with the clinical outcome. Furthermore, 87.7% of the acetabular cups were positioned within the Lewinnek safe zone, achieving successful reconstruction of the acetabular rotation center. The cup survival rate at the last follow-up was 100%.

Conclusions

The utilization of the only Chinese domestically manufactured 3D printing trabecular titanium acetabular cup in primary THA demonstrated favorable short-term clinical and radiographic outcomes. The acetabular cup exhibits excellent initial stability, high survival rate, and favorable osseointegration, leading to a significant enhancement in pain relief and functional improvement. In the future, larger sample sizes and multicenter prospective randomized controlled trials will be required to validate the long-term safety and effectiveness of this 3D ACT™ cup.

Bone Quality Assessment Before Total Hip Arthroplasty: The Role of Densitometry

Background Total hip arthroplasty (THA) is effective in the treatment of hip osteoarthritis. Radiographic evaluation, standard in THA planning, is sufficient in examining hip anatomy, although it may not precisely assess bone quality. A routinely implemented method in bone quality assessment is densitometry. The technique allows for a measurement of bone mineral density (BMD). Methodology In the study, we included 26 participants who qualified for THA. All the patients were preoperatively examined with radiographs and densitometry of the affected hip. On the preoperative anteroposterior radiograph, we measured the canal-to-calcar isthmus ratio (CC ratio) and the cortical index (CI). Intraoperatively, during the THA procedure, we measured the thickness of the cortical bone and the diameter of the femoral neck in the line of neck resection. Results The examination with Pearson's correlation coefficient revealed that BMD significantly positively correlates with the intraoperatively measured diameter of the femoral neck (r = 0.5, P = 0.009), and with the measured thickness of the cortical bone (r = 0.47, P = 0.015), CI significantly positively correlates with the intraoperatively measured diameter of the femoral neck (r = 0.6, P = 0.001), and with the CC ratio (r = 0.44, P = 0.024), the intraoperatively measured diameter of the femoral neck significantly positively correlates with the intraoperatively measured thickness of the cortical bone (r = 0.59, P = 0.001). All of the other correlations were not statistically significant. Conclusions BMD measurements can be used in THA planning as they positively correlate with intraoperative measurements. The radiological parameters (CC ratio and CI) may not be as precise in bone quality assessment.

Areal bone mineral density is not associated with femoral stem subsidence in patients younger than 70 years undergoing total hip arthroplasty

INTRODUCTION

Femoral stem subsidence is a known complication after uncemented total hip arthroplasty (THA). The purpose of this study was to determine the frequency of osteoporosis and to investigate the relationship between areal bone mineral density (aBMD) and subsidence in a cohort of patients younger than 70 years.

METHODS

One hundred consecutive patients (age 60 ± 6 years; 52 female, 48 male) undergoing uncemented THA using a collarless press fit femoral stem were retrospectively reviewed. Dual-energy X-ray absorptiometry (DXA) was performed preoperatively at the proximal femur and lumbar spine, and if not feasible at these sites, at the distal radius. DXA results were compared to a cohort of 100 patients ≥ 70 years scheduled for cemented THA. Age, sex, and body mass index (BMI), canal flare index (CFI), and canal fill ratio (CFR) were assessed. Analysis of stem subsidence and migration was performed on standardized, calibrated radiographs obtained postoperatively and at follow-up.

RESULTS

The frequency of osteoporosis was considerably lower in the study cohort compared to patients ≥ 70 years (7% vs. 19%, p = 0.02). Illustrated by the high CFR (mean 96 ± 4%) in the mid-stem region, a sufficient press fit was achieved. After a mean follow-up of 7.4 months, the mean stem subsidence was 0.9 ± 0.9 mm. Only two patients had subsidence greater than 3 mm, one of whom was morbidly obese and the other diagnosed with severe osteoporosis. There were no correlations between any of the parameters (CFI, CFR, age, sex, BMI) and femoral stem subsidence. In addition, aBMD T-scores showed no correlations with subsidence.

CONCLUSION

aBMD by DXA does not appear to be associated with stem subsidence in patients younger than 70 years and with adequate press fit.

Skeletal Status in Patients Scheduled for Elective Lumbar Spine Surgery: Comparison of Discectomy, Decompression, Fusion, and Revision

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

To investigate and compare the prevalence of low bone mineral density (BMD) and abnormal laboratory bone metabolism parameters in patients undergoing elective primary discectomy, decompression, and fusion and to outline possible differences in these parameters between patients undergoing revision for skeletal vs non-skeletal complications.

METHODS

We retrospectively evaluated BMD measurements by dual-energy x-ray absorptiometry (DXA) in 389 consecutive patients scheduled for elective lumbar spine surgery. Next to demographic characteristics, laboratory bone metabolism parameters were assessed. Group comparisons were performed between primary discectomy, decompression, and fusion. In patients scheduled for revision surgery after fusion, potential differences in the skeletal status between those with skeletal vs non-skeletal complications were analyzed.

RESULTS

Osteoporosis by T-score was detected in 6.7%, 11.0% and 14.7% of the patients undergoing discectomy, decompression and fusion, respectively. While vitamin D deficiency (67.6%) and hyperparathyroidism (16.4%) were frequently detected, no differences in laboratory bone metabolism markers could be found between the groups. Female sex (P<.001), higher age (P=.01) and lower BMI (P<.001) were associated with lower BMD. In the cohort of patients undergoing revision surgery due to complications after fusion, those with skeletal complications did not differ in BMD or bone metabolism from those with non-skeletal complications.

CONCLUSIONS

Osteoporosis represents a relevant comorbidity in patients scheduled for elective spine surgery, which is why DXA should be routinely performed in these patients. However, DXA may provide limited information in identifying patients at increased risk for skeletal complications after fusion.

Radiographic Assessment of Bone Quality Using 4 Radiographic Indexes: Canal Diaphysis Ratio Is Superior

BACKGROUND

Osteoporosis increases the risk of periprosthetic fracture and loosening in hip arthroplasty. Many methods have been proposed to assess bone quality in X-rays, including both qualitative such as the Dorr classification and quantitative such as the Calcar-Canal Ratio (CCR) and Cortical-Thickness index/Canal-Bone ratio (CTI/CBR). The Canal-Diaphysis ratio (CDR) has been described as a predictor for hip fragility fractures; however, its relationship with bone mineral density (BMD) has not been described. The purpose of this study was to evaluate the correlation of the Dorr classification, CCR, CTI/CBR, and CDR with BMD of the proximal femur in patients without hip fracture.

METHODS

Forty-seven patients over 45 years of age who had less than 6 months between radiographs and dual-energy X-ray absorptiometry were evaluated. Measurements of CCR, CBR, CDR, and Dorr classification were performed in all radiographs by 2 independent observers.

RESULTS

The CDR had a high correlation (r = 0.74, P=<0.01) with BMD, whereas the CTI/CBR had a moderate correlation (r = 0.49, P=<0.01), and the CCR had no correlation with BMD (r = 0.06, P = .96). When evaluating the receiver operating characteristic curve, CDR showed the best performance (area under curve [AUC] = 0.75) followed by CBR (AUC = 0.73) and CCR (AUC = 0.61). The optimal cutoff value for the CDR was 0.49, with 100% sensitivity and 58% specificity. The inter- and intra-observer variability was good for all methods. No differences were found between Dorr classification of patients who had or did not have osteoporosis.

CONCLUSION

Of all the analyzed methods, the CDR was found to have the best correlation with BMD. This study proposes the use of CDR as a tool for assessing bone quality when deciding the implant fixation method in hip arthroplasty.

Bone Mineral Density is Associated With Adverse Events but not Patient-Reported Outcomes in Total Hip and Knee Arthroplasty

BACKGROUND

Although osteoporosis is common in patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA), its impact on postoperative outcomes has been inadequately studied. The purpose of this study was to evaluate the impact of bone mineral density (BMD) on adverse events and patient-reported outcomes in THA and TKA.

METHODS

A series of 1,306 THA and 1,046 TKA patients who had received osteodensitometry were analyzed retrospectively. Rates of readmission, complication, transfusion, and patient-reported outcome were correlated with BMD. Multivariable logistic regression models were used to assess the relationship between osteoporosis and adverse events.

RESULTS

Osteoporosis patients showed higher rates of 90-day readmission (THA: 8.5% versus 4.0%, P = .02; TKA: 8.9% versus 4.4%, P = .04) and transfusion (THA: 6.8% versus 1.2%, P < .001; TKA: 5.4% versus 1.5%, P = .005). After THA, rates of complications requiring intensive care management (5.1% versus 0.7%, P < .001) and rates of medical complications (3.5% versus 0.6%, P = .001) were increased. After TKA, rates of surgical complications (2.8% versus 0.8%, P = .04) were increased. Postoperatively, osteoporosis patients improved to comparable patient-reported outcomes as patients who had normal BMD. Multivariable logistic regression analyses revealed osteoporosis as an independent risk factor for readmissions, complications, and transfusions.

CONCLUSION

Osteoporosis is a risk factor for adverse events after THA and TKA. Affected patients show similar improvement of patient-reported outcome compared to patients who have normal BMD. As osteoporosis is modifiable, a systematic screening of patients scheduled for THA or TKA should be discussed.

Plain radiographic indices are reliable indicators for quantitative bone mineral density in male and female patients before total hip arthroplasty

Osteoporosis is underdiagnosed in patients undergoing total hip arthroplasty (THA). Bone mineral density measurement by dual-energy X-ray absorptiometry (DXA) is the gold standard, but indices on plain hip radiographs also seemed to be reliable screening tools in female or Asian ethnicities in previous studies. Given the lack of knowledge about male patients and Caucasian ethnicities, this study was conducted to evaluate plane hip radiographic indices as a screening tool for osteopenia and osteoporosis in Caucasian female and also male patients before undergoing THA. A retrospective analysis of 216 elderly patients with pre-existing DXA before hip arthroplasty was performed and four indices were calculated on plain hip radiographs: Canal-Flare-Index (CFI), Canal-Calcar-Ratio (CCR), Canal-Bone-Ratio (CBR) 7 and 10 cm below the lesser trochanter. They were correlated with femoral neck DXA T-scores by Pearson's correlation and intraclass correlation coefficient, and a ROC analysis was performed. A total of 216 patients (49.5% male) were included. CBR-7 and -10 were highly correlated (p < 0.001) with femoral neck T-score in males (Pearson's correlation CBR-7 r = - 0.60, CBR-10 r = - 0.55) and females (r = - 0.74, r = - 0.77). CBR-7 and -10 also showed good diagnostic accuracy for osteoporosis in the ROC analysis in males (CBR-7: AUC = 0.75, threshold = 0.51; CBR-10: 0.63; 0.50) and females (CBR-7: AUC = 0.87, threshold = 0.55; CBR-10: 0.90; 0.54). Indices such as the Canal Bone Ratio (CBR) 7 or 10 cm below the lesser trochanter on plain hip radiographs are a good screening tool for osteopenia and osteoporosis on plain hip radiographs and can be used to initiate further diagnostics like the gold standard DXA. They differ between male and female patients.

The Effect of Preoperative Bisphosphonate Use on Total Hip Arthroplasty Outcomes

BACKGROUND

Patients undergoing total hip arthroplasty (THA) commonly have osteoporosis for which bisphosphonates (BPs) are Food and Drug Administration (FDA)-approved for treatment. Bisphosphonate use post-THA is associated with decreased periprosthetic bone loss or revisions, and increased longevity of implants. However, evidence is lacking for preoperative bisphosphonate use in THA recipients. This study investigated the association between bisphosphonate use pre-THA and outcomes.

METHODS

A retrospective review of a national administrative claims database was conducted. Among THA recipients who had a prior diagnosis of hip osteoarthritis and osteoporosis/osteopenia, the treatment group (BP-exposed) consisted of patients who had a history of bisphosphonate use at least 1 year before THA; controls (BP-naive) comprised patients who did not have preoperative bisphosphonate use. The BP-exposed were matched to BP-naive in a 1:4 ratio by age, sex, and comorbidities. Logistic regressions were used to calculate the odds ratio for intraoperative and 1-year postoperative complications.

RESULTS

The BP-exposed group had significantly higher rates of intraoperative and 1-year postoperative periprosthetic fractures (odds ratio (OR): 1.39, 95% confidence interval (CI): 1.23, 1.57) and revisions (OR: 1.14, 95% CI: 1.04, 1.25) compared with the BP-naive controls. BP-exposed also experienced higher rates of aseptic loosening, dislocation, periprosthetic osteolysis, and stress fracture of the femur or hip/pelvis compared to the BP-naive controls, but these values were not statistically significant.

CONCLUSION

The use of bisphosphonates in THA patients preoperatively is associated with higher rates of intraoperative and 1-year postoperative complications. These findings may impact the management of patients undergoing THA who have a prior diagnosis of osteoporosis/osteopenia and use of bisphosphonates.

LEVEL OF EVIDENCE

Retrospective Cohort Study (Level 3).

Bone remodeling and cortical thinning distal to the femoral stem: a retrospective review

INTRODUCTION

There is a paucity of information on the bone remodeling that occurs distal to the femoral stem following total hip arthroplasty as most previous studies have focused on proximal changes. In this study, we report the cortical thinning that occur distal to the femoral stem after primary total hip arthroplasty.

METHODS

A retrospective review was performed at one institution over a 5-year period. 156 primary total hip arthroplasty procedures were included. The Cortical Thickness Index (CTI) was measured on both operative and non-operative hips at 1 cm, 3 cm and 5 cm below the prosthetic stem tip on anteroposterior radiographic images pre-operatively as well as at 6 months, 12 months and 24 months post-operatively. The difference in average CTI was measured using paired t-tests.

RESULTS

There were statistically significant decreases in CTI distal to the femoral stem at 12 months and 24 months (-1.3% and -2.8%, respectively). Greater losses were seen in female patients, patients older than 75, and patients with BMI less than 35 at 6 months postoperative. There were no differences in CTI at any time point on the non-operative side.

CONCLUSION

The current study demonstrates that patients undergo bone loss as measured by CTI distal to the stem in the first 2 years following total hip arthroplasty. Comparison to the contralateral non-operative side confirms that this change is greater than expected for the natural aging process. A greater understanding of these changes will help optimize post-operative management and direct future innovations in implant design.

The effect of reduced bone mineral density on elective total hip arthroplasty outcomes

INTRODUCTION

Reduced bone mineral density (BMD) and disruption of normal bony architecture are the characteristics of osteopenia and osteoporosis and in patients undergoing total hip arthroplasty (THA) may cause failure of trabecular ingrowth. The purpose of this study is to evaluate the impact of reduced BMD on outcomes following primary elective THA.

METHODS

A retrospective chart review of 650 elective THAs with a DEXA scan in their electronic health record (EHR) from 2011 to 2020 was conducted at an urban, academic center and a regional, health center. Patients were separated into three cohorts based on their t-score and the World Health Organizations definitions: normal (t-score ≥ - 1), osteopenia (t-score < - 1.0 and > - 2.5), and osteoporosis (t-score ≤ - 2.5). Demographic and outcome data were assessed. Subsidence was assessed for patients with non-cemented THAs. Regression models were used to account for demographic differences.

RESULTS

650 elective THAs, of which only 11 were cemented, were included in the study. Patients with osteopenia and osteoporosis were significantly older than those without (p = 0.002 and p < 0.0001, respectively) and had a lower BMI (p < 0.0001 and p < 0.0001, respectively). PFx was significantly greater in patients with osteoporosis when compared to those with normal BMD (6.5% vs. 1.0%; p = 0.04). No such difference was found between osteoporotic and osteopenic patients. The revision rate was significantly higher for osteoporotic patients than osteopenic patients (7.5% vs. 1.5%; p = 0.04). No such difference was found between the other comparison groups.

CONCLUSION

Patients with osteoporosis were older with reduced BMI and had increased PFx after non-cemented elective THA. Understanding this can help surgeons formulate an appropriate preoperative plan for the treatment of patients with osteoporotic bone undergoing elective THA.

Severe intraoperative vascular bleeding as main complication of acetabular fractures treated with plate osteosynthesis via the modified Stoppa approach

Acetabular fractures are challenging fractures and finding the best supportive treatment is complex. Many operative treatment options exist - one of them is the plate osteosynthesis via the modified Stoppa approach gaining popularity over the last decades. The purpose of this study is to give an overview of this surgical techniques and its main complications. Patients ≥ 18 years between the years 2016 and 2022 with acetabular fractures in our department received a surgical intervention with plate fixation via the modified Stoppa approach. All protocols and documents during a patient's hospital stay were analyzed to find relevant perioperative complications concerning this operative technique. Between 01/2016 und 12/2022 75 patients with acetabular fractures were treated surgically in the author's institution with a plate osteosynthesis via the modified Stoppa approach. In 26.7 % (n = 20) of all cases, patients were confronted with one or more perioperative complications typical for this operation. Intraoperative venous bleedings were the main complication with 10.6 % (n = 8). Postoperative functional impairment of the obturator nerve and deep vein thrombosis occurred with 2.7 % (n = 2) and 9.3 % (n = 7). This retrospective study shows that plate fixation via the Stoppa approach is a good treatment option because of the excellent intraoperative overview of the fracture, but has its pitfalls and complications. Especially severe vascular bleedings must be taken into account and its management well known.

Evaluation of FRAX in patients with periprosthetic fractures following primary total hip and knee arthroplasty

The fracture risk assessment tool (FRAX) is a tool which calculates an individual 10-year fracture risk based on epidemiological data in patients with a risk of osteporosis. The aim of this study was to evaluate the value of FRAX to estimate the risk of postoperative periprosthetic fractures (PPF) in patients following with total hip and knee arthroplasty. 167 patients (137 periprosthetic fractures in total hip arthroplasty and 30 periprosthetic fractures in total knee arthroplasty) were included in this study. Patients' data was retrieved retrospectively. In each patient the 10-year probability of a major osteoporotic fracture (MOF) and an osteoporotic hip fracture (HF) was calculated using FRAX. According to the NOGG guideline 57% of total hip arthroplasty (THA) patients and 43.3% of total knee arthroplasty (TKA) patients were in need of osteoporosis treatment, whereas only 8% and 7% received an adequate one respectively. 56% of the patients with PPF after THA and 57% of the patients with PPF after TKA reported about a previous fracture. Significant associations between the 10-year probability of a MOF and HF calculated by FRAX and PPF in THA and TKA were seen. The results of the present study show that FRAX might have the potential to estimate the PPF in patients following THA and TKA. FRAX should be calculated before and after THA or TKA in order to assess the risk and counsel patients. The data show a clear undertreatment of patients with PPF in respect to osteoporosis.

A Comparison of Radiographic Outcomes after Total Hip Arthroplasty between the Direct Lateral Approach and Posterior Lateral Approach with EOS 2D/3D X-Ray Imaging System

OBJECTIVE

The classical approaches for total hip arthroplasty (THA) are the direct lateral approach (DLA) and posterior lateral approach (PLA). There are few studies comparing implant orientation with these two approaches, and the impact of surgical approaches on implant orientation remains controversial. With the rise of the EOS imaging system, we aimed to use it to identify the differences between and factors associated with implant orientation after THA using DLA and PLA.

METHODS

In our department from January 2019 to December 2021, 321 primary unilateral THAs that used PLA and DLA were enrolled. A total of 201 patients who received PLA and 120 patients who received DLA were included in this study. Two blinded observers measured each case using EOS imaging data. Postoperative imaging metrics and other relevant influencing factors of the two surgical approaches were compared. Postoperative imaging metrics, including the anteversion and inclination of the cup, anteversion of the stem, and combined anteversion were measured based on EOS. Other relevant influencing factors included age, approach, gender, laterality, BMI, anterior pelvic plane inclination, femoral head diameter, femoral offset, lateral pelvic tilt, pelvic incidence, pelvis axial rotation, sacral slope, sagittal pelvic tilt, and surgery time. Multiple linear regression analyses were performed to identify the predictors of acceptability for each imaging data point.

RESULTS

No dislocation was found in the 321 patients who underwent primary THA during this period. The mean anteversion and combined anteversion of the cups using the DLA were 21.33° ± 17.31° (-51.7°-60.8°) and 33.71° ± 20.85° (-38.8°-77.6°) and PLA were 25.34° ± 12.76° (-5.5°-57.0°) and 42.37° ± 18.85° (-8.7°-84.7°), respectively. The DLA group had smaller anteversion (p = 0.038) and combined anteversion (p < 0.001). We found that surgical approach (p < 0.05), anterior pelvic plane inclination (p < 0.001), gender (p < 0.001), and femoral head diameter (p < 0.001) were important factors affecting acetabular cup anteversion (R2  = 0.375) and combined anteversion (R2  = 0.525).

CONCLUSIONS

In total hip arthroplasty, different prosthesis installation directions should be made according to different surgical approaches. Compared with the direct lateral approach, the acetabular anteversion can be intentionally enlarged when using the posterolateral approach. Surgical approach, anterior pelvic plane inclination (APPI), gender, and femoral head diameter were significant predictors of prosthesis orientation. The anterior pelvic plane inclination may be a useful standard for assessing the position of the prosthesis using EOS.

The effect of contrast media on CT measures of bone mineral density: a systematic review

OBJECTIVE

The aim was to systematically assess the literature on possible effect of administration of iodinated contrast media on CT-estimated bone mineral density (BMD).

MATERIALS AND METHODS

The Web of Science and PubMed databases were searched. Studies that used both CT principles of BMD measurement (volumetric quantitative BMD and CT attenuation in Hounsfield Units) were included. The baseline patient data, skeletal site, contrast medium data (if reported), and change in BMD on contrast-enhanced CT scans were collected.

RESULTS

Sixteen studies met our review criteria, the majority of which was performed on lumbar spine, and the others on proximal femur. Almost all studies reported a significant increase in BMD values on the contrast-enhanced CT scans, ranging from 0.8 to 30.3%. The increase was most frequently reported to be about 10 to 15% for the spine and 5 to 10% for the femur. In addition to the difference in skeletal site, some authors found the contrast effect was age-, sex-, and contrast dose-dependent. BMD values in arterial phase were generally somewhat lower than in venous phase, and the effect of contrast in venous phase was more predictable.

CONCLUSION

The review revealed significant changes in BMD values between unenhanced and contrast-enhanced CT. The change was more pronounced in lumbar spine than in proximal femur and appeared to depend on age, sex, contrast dose, and postcontrast imaging protocol. The review suggests the understanding of all mentioned factors during the interpretation of BMD measured on contrast-enhanced CT.

Periprosthetic fractures: an unrecognized osteoporosis crisis

Total joint replacement is common and increasing. Many of these patients have low bone mineral density preoperatively, and arthroplasty leads to bone loss. As falls are common before and after arthroplasty, it is unsurprising that periprosthetic fractures, defined as those associated with an orthopedic device, whether a joint replacement or other internal fixation devices, are not rare. These fractures engender morbidity and mortality comparable to osteoporosis-related hip fractures but remain largely unrecognized and untreated by osteoporosis/metabolic bone disease clinicians. Indeed, recent osteoporosis guidelines are silent regarding periprosthetic fractures. The purposes of this clinical review are to briefly describe the epidemiology of arthroplasty procedures and periprosthetic fractures, raise awareness that these fractures are osteoporosis-related, and suggest approaches likely to reduce their occurrence. Notably, bone health evaluation is essential following the occurrence of a periprosthetic fracture to reduce subsequent fracture risk. Importantly, in addition to such secondary fracture prevention, primary prevention, i.e., bone health assessment and optimization prior to elective orthopedic procedures, is appropriate.

Intraperitoneal Loss of Pelvic Array Pin During Navigated Total Hip Arthroplasty

Pelvic array pin placement during navigated total hip arthroplasty has been known to cause complications; however, most of them are minor. We report a 78-year-old female who underwent a routine computer-navigated total hip replacement which was subsequently complicated by complete loss of the pelvic array pin requiring retrieval via laparotomy. No structures were injured despite the surrounding urological, vascular, and visceral anatomy. The patient recovered and subsequently underwent a total hip arthroplasty without complication 6 weeks later. This case illustrates the dangers of inserting a pelvic array pin within patients with poor bone quality and highlights necessary considerations of pin design and surgical techniques to minimize this complication.

Prevalence of osteoporosis and osteopenia in elderly patients scheduled for total knee arthroplasty

INTRODUCTION

Osteoporosis is a common comorbidity in elderly patients with osteoarthritis (OA) and may increase perioperative complications in orthopedic surgery (e.g., component migration, periprosthetic fractures). As there is no investigation of bone mineral density (BMD) in elderly patients prior to total knee arthroplasty (TKA) in Europe, we investigated this issue with a particular focus on a potential treatment gap.

MATERIALS AND METHODS

We assessed the BMD by dual-energy X-ray absorptiometry (DXA) in 109 consecutive elderly patients (age ≥ 70 years) scheduled for TKA. In addition to a detailed assessment of osteoporosis and osteopenia, the influence of clinical risk factors and radiological OA severity on BMD was evaluated using group comparisons and linear regression models. In addition, we analyzed differences in BMD between patients scheduled for TKA vs. total hip arthroplasty (THA).

RESULTS

Of the included 109 patients, 19 patients (17.4%) were diagnosed with osteoporosis and 50 (45.9%) with osteopenia. In the osteoporotic patients, a clinically relevant underdiagnosis concomitant with a serious treatment gap was observed in 95.0% of the patients. Body mass index, OA grade, and glucocorticoid use were identified as independent factors associated with BMD. No differences in BMD were found between the patients scheduled for TKA vs. THA.

CONCLUSIONS

Considering the high prevalence of osteoporosis and osteopenia in elderly patients, DXA screening should be recommended for patients ≥ 70 years indicated for TKA.

Total Joint Arthroplasty and Osteoporosis: Looking Beyond the Joint to Bone Health

BACKGROUND

Metabolic bone diseases in the total joint arthroplasty (TJA) population are undertested and undertreated, leading to increased risk of adverse outcomes such as periprosthetic fractures. This study aims to better characterize the current state of bone care in TJA patients using Fracture Risk Assessment Tool (FRAX) score risk stratifications.

METHODS

In total, 505 consecutive TJA patients who meet the Endocrine Society guidelines for osteoporosis screening were included for review. They were divided into a high risk or low risk group depending on FRAX scores and were compared based on screening, diagnosis, and treatment of metabolic bone disease. Logistic regression models were used to analyze factors influencing screening and treatment. A population analysis involving 2,000 TJA patients, and a complication analysis involving 40 periprosthetic fracture patients were conducted.

RESULTS

Among high risk patients undergoing TJA, 90% did not receive any pharmacological treatment for osteoporosis, 45% were not treated with vitamin D or calcium, and 88% did not receive bone density testing in the routine care period. Among patients with pre-existing osteoporosis undergoing TJA, 80% were not treated with any osteoporosis medications and 33% of these patients were not taking vitamin D or calcium. Female gender and past fracture history contributed to whether patients received screening and treatment. Patients with periprosthetic hip fractures have significantly higher FRAX scores compared to control THA patients.

CONCLUSION

There are significant gaps in metabolic bone care of the geriatric TJA population regarding both screening and treatment. Metabolic bone care and risk identification with FRAX should be highly considered for TJA patients.

[Patient optimization before hip revision arthroplasty: : How to handle comorbidities]

Preoperative optimization of the therapeutic regime of comorbidities can lead to an improvement of the postoperative outcome and has the potential to reduce the financial burden on the health care system in revision hip arthroplasty. Patient-related factors and an increasing incidence of comorbidities lead to a higher risk of implant failure and revision for all causes. Important and potentially modifiable risk factors like preoperative anemia, coagulopathy, infectious disease (dental status, urinary tract infections, colonization with staphylococcus), metabolic conditions (obesity, malnutrition, diabetes mellitus, osteoporosis), and smoking need to be addressed. To achieve an optimal preoperative condition a multidisciplinary approach should be applied.

Acetabular fractures treatment needs in the elderly and nonagenarians

Different treatment options for acetabular fractures in the elderly and nonagenarians exist; a consistent guideline has not been established, yet. The purpose of this study is to give an overview of how those fractures can be handled and compares two different surgical treatment methods. A total of 89 patients ≥ 18 years between 2016 and 2021 with acetabular fractures in our department received a surgical intervention with plate fixation via the Stoppa approach or a total hip arthroplasty with a Burch-Schneider ring and integrated cup. 60 patients ≥ 65 were compared in two groups, 29 patients between 65 and 79 and 31 patients ≥ 80. For comparison, data on operation times, hospitalization, complications during operation and hospital stay, blood loss and postoperative mobilization were collected. Characteristics could be found for indications for operative osteosynthesis or endoprosthetics based on the X-ray analysis. There was a tendency to treat simple fractures with osteosynthesis. Patients between 65 and 79 with an osteosynthesis had benefits in almost every comparison. Patients ≥ 80 with a plate fixation had advantages in the categories of postoperative complications, blood loss and transfusion of erythrocyte concentrates. Statistical significant differences were noticed in both groups regarding the operation time. Patients between 65 and 79 with osteosynthesis had significant benefits for postoperative complications, hospitalization, number of blood transfusions and postoperative mobilization. Finding the best supportive treatment option is difficult, and decision-making must respect fracture patterns and individual risk factors. This study shows that plate fixation via the Stoppa approach has some benefits.

Artificial Neural Networks Can Predict Early Failure of Cementless Total Hip Arthroplasty in Patients With Osteoporosis

BACKGROUND

Total hip arthroplasty (THA) done in the aging population is associated with osteoporosis-related complications. The altered bone density in osteoporotic patients is a risk factor for revision surgery. This study aimed to develop and validate machine learning (ML) models to predict revision surgery in patients with osteoporosis after primary noncemented THA.

METHODS

We retrospectively reviewed a consecutive series of 350 patients with osteoporosis (T-score less than or equal to -2.5) who underwent primary noncemented THA at a tertiary referral center. All patients had a minimum 2-year follow-up (range: 2.1 to 5.6). Four ML algorithms were developed to predict the probability of revision surgery, and these were assessed by discrimination, calibration, and decision curve analysis.

RESULTS

The overall incidence of revision surgery was 5.2% at a mean follow-up of 3.7 years after primary noncemented THA in osteoporotic patients. Revision THA was done because of periprosthetic fracture in nine patients (50%), aseptic loosening/subsidence in five patients (28%), periprosthetic joint infection in two patients (11%) and dislocation in two patients (11%). The strongest predictors for revision surgery in patients after primary noncemented THA were female sex, BMI (>35 kg/m2), age (>70 years), American Society of Anesthesiology score (≥3), and T-score. All four ML models demonstrated good model performance across discrimination (AUC range: 0.78 to 0.81), calibration, and decision curve analysis.

CONCLUSION

The ML models presented in this study demonstrated high accuracy for the prediction of revision surgery in osteoporotic patients after primary noncemented THA. The presented ML models have the potential to be used by orthopaedic surgeons for preoperative patient counseling and optimization to improve the outcomes of primary noncemented THA in osteoporotic patients.

Radiographic indexes in AP hip radiographs prior to total hip arthroplasty reveal candidates with low BMD

Using anteroposterior (AP) hip radiograph, we measured several indexes to investigate the association with bone mineral density (BMD) before THA and found a highly effective index to predict femoral BMD. This technique is helpful for both patients and clinicians to identify potential candidates with low BMD to whom DXA examination is particularly recommended.

INTRODUCTION

The purpose of the study is to identify patients with low bone mineral density (BMD) prior to total hip arthroplasty with the help of AP hip radiographs.

METHODS

Indexes on AP hip radiographs and T-scores from DXA examination of the lumbar spine and the affected hip were acquired from patients before THA. Indexes measured on AP hip radiographs including the canal calcar ratio (CCR), canal flare index (CFI), morphological cortical index (MCI), canal bone ratio (CBR), and canal bone area ratio (CBAR). The relevance between indexes and the T-score of femora was evaluated by correlation analysis, and the diagnostic value of indexes for osteopenia was examined by receiver operating characteristic (ROC) curves.

RESULTS

A total of 81 patients were included. The average value of CBR-7, CBR-10, and CBAR (7-10) were highly related to the T-score of femora (r =  - 0.592, r =  - 0.634, and r =  - 0.631, respectively, p < 0.0001). Results of the intra- and interobserver variation assessment was excellent. CBR-7, CBR-10, and CBAR (7-10) were significantly different between the non-osteopenia and osteopenia groups (p < 0.0001). CBR-10 had the biggest area under curve (AUC), means the great diagnostic value for osteopenia in the proximal femora (AUC = 0.821, cutoff value = 0.3805).

CONCLUSION

The canal bone ratio at 10 × 10^-2 m under the level of the lesser trochanter proved to be a great indicator of femoral osteopenia. Trial registration Chinese Clinical Trail Registry, ChiCTR2000041016. Registered 16 December 2020-Retrospectively registered, http://www.chictr.org.cn/listbycreater.aspx .

Sex- and Age-Related Dynamic Changes of the Macroelements Content in the Femoral Bone with Hip Osteoarthritis

Simple Summary

The study assessed the content of macroelements Ca, Mg, P, and Na in the proximal femoral bone tissue in patients with hip osteoarthritis, and it correlated with age, sex, and BMI. The high reduction of macroelements in the femoral bone of patients with hip osteoarthritis is more pronounced in the cortical bone and occurs in women under 60 years of age. In men, it begins in the seventh and increases in the eighth decade of life.

Abstract

Background: The content of macroelements in bones varies with age and depends on sex. The aim of the study was to evaluate the content of macroelements and its correlation with age and sex in the femoral bone obtained during total hip arthroplasty. Methods: In the 86 patients, the content of macroelements (Ca, P, Mg, and Na) in the femoral head and neck (cancellous and cortical bone) was assessed by means of the inductively coupled plasma optical emission spectrometry analytical technique (ICP-OES). Results: There was a decrease in the content of macroelements in the cortical bone with age in the women in the 51–60 years (statistically significant: −0.59 for Ca, −0.65 for P) and over 70 years age groups (correlation not statistically significant: −0.29 for Ca, −0.38 for P). A significant decrease in the content of macroelements in the cortical bone was found in men over 70 years of age. Conclusions: Patterns of increased loss of macronutrients (Ca, P, and Mg) in the femoral neck (cortical bone) were demonstrated in the following patients with osteoarthritis: women aged 51–60 years and patients of both sexes over 70 years of age.

Prevalence and treatment rate of osteoporosis in patients undergoing total knee and hip arthroplasty: a systematic review and meta-analysis

PURPOSE

Due to age and gender, patients awaiting total knee or hip arthroplasty (TKA/THA) are at a higher risk of osteoporosis. In joint arthroplasty, low bone mineral density (BMD) is a risk factor for implant osseointegration, durability, and prosthesis complications. This study aims to investigate the prevalence and treatment rate of osteoporosis in patients undergoing total joint arthroplasty (TJA).

METHODS

We applied a comprehensive literature search through PubMed, Cochrane Library, and EMBASE from inception to July 10, 2021, for studies investigating the prevalence and treatment rate of osteoporosis in TJA patients. The aggregated prevalence was calculated with the random-effects model, and the heterogeneity between studies was checked by Cochran's Q test and quantified by the I² statistic. We performed subgroup analyses and meta-regression analyses to determine the source of heterogeneity. Publication bias was assessed by a funnel plot and verified by Egger's test. Anti-osteoporosis treatment for TJA patients was described qualitatively and quantitatively.

RESULTS

Of 4561 citations identified by the search strategy, 11 studies including 3462 patients were eligible for inclusion. The pooled prevalence of osteoporosis and osteopenia in TJA patients was 24.8% (95%CI: 14.1-37.2%) and 38.5% (95%CI: 29.3-48.0%), respectively. The prevalence of osteoporosis/osteopenia in TJA patients was 64.0% (95%CI: 45.8-80.3%). In terms of gender, the pooled prevalence of osteoporosis in males, females, and postmenopausal females were 5.5% (95%CI: 1.5-11.4%), 29.0% (95%CI: 18.3-41.1%), and 38.3% (95%CI: 13.2-67.1%), respectively. The treatment rate of osteoporosis in TJA patients was 32.9% (95%CI: 15.2-53.1%) by a random-effects model.

CONCLUSIONS

Osteoporosis is highly prevalent in patients undergoing TJA, especially in postmenopausal females. However, the treatment rate of osteoporosis is low. Considering the possibility of surgical complications, clinicians should strengthen their awareness of pre-operative BMD assessment and manage osteoporosis in high-risk patients.