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Li J, Zhang M, Yao J, Long S, Fang C, Cheng CK. Risk Factors for Periprosthetic Femoral Fractures after Cementless Total Hip Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00581-3. [PMID: 38851406 DOI: 10.1016/j.arth.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 05/31/2024] [Accepted: 06/03/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND The present study aimed to identify the risk factors of periprosthetic femoral fracture (PFF) after cementless total hip arthroplasty (THA) and rank them based on importance. METHODS The age, sex, body mass index (BMI), osteoporosis, canal flare index (CFI), canal bone ratio (CBR), canal calcar ratio (CCR), stem design, and stem canal fill ratio (P1, P2, P3, and P4) of the proximal femoral medullary cavity of 111 THA patients who had PFF and 388 who did not have PFF were analyzed. Independent-samples student t-tests were used for continuous variables, and Chi-square tests were used for categorical variables. The importance rankings of influencing factors were assessed using a random forest algorithm. Dimensionally reduced variables were then incorporated into a binary logistic regression model to determine the PFF-related risk factors. RESULTS The mean age, BMI, CBR, CCR, and incidence of osteoporosis were higher in cases of PFF (all P < 0.001), while the mean CFI, P1, P2, P3, and P4 were lower in cases of PFF (P < 0.001, P = 0.033, P = 0.008, P < 0.001, and P < 0.001, respectively). Additionally, the stem design was also statistically associated with PFF (P < 0.001). Multivariate logistic regression revealed that advanced age, higher BMI, osteoporosis, stem design, lower CFI, higher CBR, higher CCR, lower P1, lower P2, lower P3, and lower P4 were the risk factors of PFF (P < 0.001, P < 0.001, P < 0.001, P < 0.001, P < 0.001, P = 0.010, P < 0.001, P = 0.002, P < 0.001, P < 0.001, and P = 0.007, respectively). The ranked importance of the risk factors for PFF was P3, CFI, osteoporosis, CBR, age, P4, P1, stem design, CCR, BMI, and P2. CONCLUSION Lower P3, lower CFI, osteoporosis, higher CBR, advanced age, lower P4, lower P1, stem design, higher CCR, higher BMI, and lower P2 increased the risk of PFF.
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Affiliation(s)
- Junwei Li
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Min Zhang
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Jie Yao
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Shao Long
- Department of joint surgery, No.6 Hospital of Ningbo, Zhejiang, China
| | - Chaohua Fang
- Department of Sports Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Bengbu Hospital of Shanghai General Hospital (The Second Affiliated Hospital of Bengbu Medical University), Anhui, China.
| | - Cheng-Kung Cheng
- School of Biomedical Engineering and Engineering Research Center for Digital Medicine of the Ministry of Education, Shanghai Jiao Tong University, Shanghai, China.
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Kuyl EV, Agarwal AR, Patel PK, Harris AB, Gu A, Rao S, Thakkar SC, Golladay GJ. 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. J Arthroplasty 2024; 39:1285-1290.e1. [PMID: 37952741 DOI: 10.1016/j.arth.2023.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/30/2023] [Accepted: 11/04/2023] [Indexed: 11/14/2023] Open
Abstract
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.
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Affiliation(s)
- Emile-Victor Kuyl
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Amil R Agarwal
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Parth K Patel
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Andrew B Harris
- Department of Orthopaedic Surgery, Johns Hopkins Medicine, Baltimore, Maryland
| | - Alex Gu
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Sandesh Rao
- Washington Orthopaedics and Sports Medicine, Washington, District of Columbia
| | | | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
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Chen JJ, Hung SH, Liou JY, Chang WC, Hsu KH, Su YP, Chiu FY, Cheng MF. Long stem revision versus short stem revision with plate osteosynthesis for Vancouver type B2 periprosthetic femoral fracture: a comparative study of eighty five cases. INTERNATIONAL ORTHOPAEDICS 2024:10.1007/s00264-024-06181-w. [PMID: 38652245 DOI: 10.1007/s00264-024-06181-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Periprosthetic femoral fractures (PPFs) around the hip are challenging complications in orthopaedic surgery, particularly Vancouver type B2 (VTB2) fractures. The surgical management of these fractures is crucial and depends on various factors. Cementless short taper stem with plate osteosynthesis is an alternative surgical technique. This study aims to compare the outcomes of this surgical technique with revision arthroplasty (RA) with long stem in the treatment of VTB2 PPFs. METHODS This retrospective study was conducted in a single medical institute from February 2010 to May 2019. Patients who had received either total hip arthroplasty or bipolar hemiarthroplasty and subsequently developed a VTB2 PPF were included; patients who sustained intra-operative fractures or received a cemented stem previously were excluded from the analysis. The patients were divided into two groups: group I received RA with cementless long stem, while group II underwent RA with cementless short taper stem with plate osteosynthesis. Demographic data, radiographic and functional outcomes, and complications were analyzed between the two groups. RESULTS A total of 85 patients diagnosed with VTB2 PPFs were included in the study. There were no significant differences between the two groups in terms of demographic data, including age, gender, mean follow-up times, estimated blood loss, and operative times. The radiographic results showed that there was no significant difference in the incidence of subsidence and implant stability between the two groups. However, group II tended to have less subsidence and periprosthetic osteolysis. Patients in group II had significantly better functional scores (mean Harris hip score: post-operative: 60.2 in group I and 66.7 in group ii; last follow-up: 77.4 in group 1 and 83.2 in group II (both p < 0.05)). There were no significant differences in the overall complication rate, including infection, dislocation, re-fracture, and revision surgery, between the two groups. CONCLUSIONS Both surgical techniques, cementless long stem and cementless short taper stem with plate osteosynthesis, are effective in the treatment of Vancouver B2 PPFs, with no significant differences in outcomes or complications. However, patients in cementless short taper stem with plate osteosynthesis had better functional scores at both post-operative and the last follow-up.
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Affiliation(s)
- Jian-Jiun Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital Shipai Rd Beitou Dist, No. 201, Sec. 2, Taipei City, 112201, Taiwan, Republic of China
- Department of Orthopedic Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Hsin Hung
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Nursing, Chang Jung Christian University, Tainan, Taiwan
| | - Jia-You Liou
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Chieh Chang
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital Shipai Rd Beitou Dist, No. 201, Sec. 2, Taipei City, 112201, Taiwan, Republic of China
- Department of Orthopedic Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuei-Hsiang Hsu
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital Shipai Rd Beitou Dist, No. 201, Sec. 2, Taipei City, 112201, Taiwan, Republic of China
- Department of Orthopedic Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Pin Su
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital Shipai Rd Beitou Dist, No. 201, Sec. 2, Taipei City, 112201, Taiwan, Republic of China
- Department of Orthopedic Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fang-Yao Chiu
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital Shipai Rd Beitou Dist, No. 201, Sec. 2, Taipei City, 112201, Taiwan, Republic of China
- Department of Orthopedic Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming-Fai Cheng
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital Shipai Rd Beitou Dist, No. 201, Sec. 2, Taipei City, 112201, Taiwan, Republic of China.
- Department of Orthopedic Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Ledford CK, Shirley MB, Spangehl MJ, Berry DJ, Abdel MP. Do breast cancer patients have increased risk of complications after primary total hip and total knee arthroplasty? Bone Joint J 2024; 106-B:365-371. [PMID: 38555948 DOI: 10.1302/0301-620x.106b4.bjj-2023-0968.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Aims Breast cancer survivors have known risk factors that might influence the results of total hip arthroplasty (THA) or total knee arthroplasty (TKA). This study evaluated clinical outcomes of patients with breast cancer history after primary THA and TKA. Methods Our total joint registry identified patients with breast cancer history undergoing primary THA (n = 423) and TKA (n = 540). Patients were matched 1:1 based upon age, sex, BMI, procedure (hip or knee), and surgical year to non-breast cancer controls. Mortality, implant survival, and complications were assessed via Kaplan-Meier methods. Clinical outcomes were evaluated via Harris Hip Scores (HHSs) or Knee Society Scores (KSSs). Mean follow-up was six years (2 to 15). Results Breast cancer patient survival at five years was 92% (95% confidence interval (CI) 89% to 95%) after THA and 94% (95% CI 92% to 97%) after TKA. Breast and non-breast cancer patients had similar five-year implant survival free of any reoperation or revision after THA (p ≥ 0.412) and TKA (p ≥ 0.271). Breast cancer patients demonstrated significantly lower survival free of any complications after THA (91% vs 96%, respectively; hazard ratio = 2 (95% CI 1.1 to 3.4); p = 0.017). Specifically, the rate of intraoperative fracture was 2.4% vs 1.4%, and venous thromboembolism (VTE) was 1.4% and 0.5% for breast cancer and controls, respectively, after THA. No significant difference was noted in any complications after TKA (p ≥ 0.323). Both breast and non-breast cancer patients experienced similar improvements in HHSs (p = 0.514) and KSSs (p = 0.132). Conclusion Breast cancer survivors did not have a significantly increased risk of mortality or reoperation after primary THA and TKA. However, there was a two-fold increased risk of complications after THA, including intraoperative fracture and VTE.
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Affiliation(s)
- Cameron K Ledford
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Matthew B Shirley
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark J Spangehl
- Department of Orthopedic Surgery, Mayo Clinic, Scottsdale, Arizona, USA
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Putra DP, Mustamsir E, Phatama KY, Pradana AS, Pratama YA. The effectiveness ORIF for neglected periprosthetic femoral fractures after hemiarthroplasty: A case report. Int J Surg Case Rep 2024; 115:109285. [PMID: 38266366 PMCID: PMC10832499 DOI: 10.1016/j.ijscr.2024.109285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Periprosthetic fractures are a growing concern due to the increasing frequency of primary joint replacement surgery, with total hip arthroplasty being the most common. The incidence of periprosthetic fractures after revision surgery ranges from 4 to 11 %, with up to 30 % reported after knee revision surgery. This case report aims to describe the treatment of an 81-year-old woman suffering from neglected periprosthetic femoral fracture post hemiarthroplasty. CASE PRESENTATION An 81-year-old woman with a history of hemiarthroplasty surgery and hypertension was admitted to the ER with pain in her right thigh. She had a middle shaft femoral fracture and was scheduled for open reduction and internal fixation. Despite being fully conscious and having an average pulse rate and blood pressure, she had cardiomegaly and congestive pulmonum. Unfortunately, this patient did not receive appropriate medical treatment after it occurred for 1 month. After surgery, we evaluated the implant, and the implant stabilized the fracture. After 1-3 months after surgery, the LEFS (The Lower Extremity Functional Scale) score was found that the score increase significantly after surgery. CLINICAL DISCUSSION The Vancouver classification system manages periprosthetic fractures by assessing location, stability, and bone quality. Type A fractures involve the trochanter, while type B fractures are diaphyseal and can extend distally. ORIF is used for subtype B1 fractures, but newer techniques offer shorter operating times and fewer complications. CONCLUSION From this study, we can conclude that even though neglected cases procedure with ORIF promises a good outcome based on clinical evaluation.
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Affiliation(s)
- Domy Pradana Putra
- Orthopaedics and Traumatology Department, Faculty of Medicine, Universitas Brawijaya - Saiful Anwar General Hospital, Malang, East Java, Indonesia.
| | - Edi Mustamsir
- Orthopaedics and Traumatology Department, Faculty of Medicine, Universitas Brawijaya - Saiful Anwar General Hospital, Malang, East Java, Indonesia
| | - Krisna Yuarno Phatama
- Orthopaedics and Traumatology Department, Faculty of Medicine, Universitas Brawijaya - Saiful Anwar General Hospital, Malang, East Java, Indonesia
| | - Ananto Satya Pradana
- Orthopaedics and Traumatology Department, Faculty of Medicine, Universitas Brawijaya - Saiful Anwar General Hospital, Malang, East Java, Indonesia
| | - Yudit Alfa Pratama
- Orthopaedics and Traumatology Department, Faculty of Medicine, Universitas Brawijaya - Saiful Anwar General Hospital, Malang, East Java, Indonesia
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Sebro R, Elmahdy M. Machine Learning for Opportunistic Screening for Osteoporosis and Osteopenia Using Knee CT Scans. Can Assoc Radiol J 2023; 74:676-687. [PMID: 36960893 DOI: 10.1177/08465371231164743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
PURPOSE To predict whether a patient has osteoporosis/osteopenia using the attenuation of trabecular bone obtained from knee computed tomography (CT) scans. METHODS Retrospective analysis of 273 patients who underwent contemporaneous knee CT scans and dual-energy X-ray absorptiometry (DXA) within 1 year. Volumetric segmentation of the trabecular bone of the distal femur, proximal tibia, patella, and proximal fibula was performed to obtain the bone CT attenuation. The data was randomly split into training/validation (78%) and test (22%) datasets and the performance in the test dataset were evaluated. The predictive properties of the CT attenuation of each bone to predict osteoporosis/osteopenia were assessed. Multivariable support vector machines (SVM) and random forest classifiers (RF) were used to predict osteoporosis/osteopenia. RESULTS Patients with a mean age (range) of 67.9 (50-87) years, 85% female were evaluated. Seventy-seven (28.2%) of patients had normal bone mineral density (BMD), 140 (51.3%) had osteopenia, and 56 (20.5%) had osteoporosis. The proximal tibia had the best predictive ability of all bones and a CT attenuation threshold of 96.0 Hounsfield Units (HU) had a sensitivity of .791, specificity of .706, and area under the curve (AUC) of .748. The AUC for the SVM with cubic kernel classifier (AUC = .912) was better than the RF classifier (AUC = .683, P < .001) and better than using the CT attenuation threshold of 96.0 HU at the proximal tibia (AUC = .748, P = .025). CONCLUSIONS Opportunistic screening for osteoporosis/osteopenia can be performed using knee CT scans. Multivariable machine learning models are more predictive than the CT attenuation of a single bone.
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Affiliation(s)
- Ronnie Sebro
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
- Centre for Augmented Intelligence, Mayo Clinic, Jacksonville, FL, USA
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Mahmoud Elmahdy
- Centre for Augmented Intelligence, Mayo Clinic, Jacksonville, FL, USA
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
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Miettinen S, Sund R, Törmä S, Kröger H. How Often Do Complications and Mortality Occur After Operatively Treated Periprosthetic Proximal and Distal Femoral Fractures? A Register-based Study. Clin Orthop Relat Res 2023; 481:1940-1949. [PMID: 37036391 PMCID: PMC10499103 DOI: 10.1097/corr.0000000000002638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/25/2023] [Accepted: 03/07/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND The incidence of periprosthetic femoral fractures is increasing because of an increasing number of primary THAs and TKAs. High rates of complications and mortality are associated with periprosthetic fractures, but few studies have evaluated and compared the population-based incidences of these events after fractures. QUESTIONS/PURPOSES (1) What is the annual incidence of periprosthetic fractures treated with surgery in one hospital district in Finland? (2) How are those incidences changing over time? (3) What is the risk of complications, reoperations, and death after those injuries? METHODS This register-based study evaluated 2259 patients who underwent revision THA or TKA or any surgery for a femoral fracture between January 2004 and December 2016 at the only hospital in our district where these types of operations are performed. During the study period, the diagnosis and operation codes of the operated-on patients varied greatly, and they were somewhat inaccurate. We thus evaluated radiographs of all 2259 patients one by one, and created inclusion and exclusion criteria based on radiologic findings and medical records. Of those, 12% (279 of 2259) had periprosthetic fractures that met the inclusion criteria, and from these, we formed two study groups (periprosthetic proximal femur fractures, n = 171; periprosthetic distal femur fractures, n = 108). Eighty-eight percent (1980 of 2259) of the patients were excluded because they were treated for a condition other than periprosthetic femoral fracture. The follow-up period ended in December 2019 or at the time the patient died. To evaluate the population-based incidence, we drew the number of individuals with THA or TKA in the hospital district from the Finnish Arthroplasty Register and the Finnish Hospital Discharge Register. The characteristics of patients with operatively treated periprosthetic femoral fractures were evaluated in terms of age, gender, fracture type, implant type, and time from the index operation to periprosthetic fracture. The annual incidences of periprosthetic femoral fractures are summarized per 1000 person-years of individuals living with an implanted THA or TKA and per 100,000 individuals per year living in our hospital district. The risks of death, complications, and reoperations were evaluated for both groups, and comparisons were made in terms of patient characteristics. RESULTS The mean annual incidence of operatively treated periprosthetic proximal femur fractures per 1000 people living with THA implants was 2.3 ± 0.9 (95% confidence interval 1.8 to 2.7) per year, and for those with periprosthetic distal femur fractures with TKA implants, it was 1.3 ± 0.6 (95% CI 1.0 to 1.7). There was an increasing trend in the incidence of periprosthetic proximal femur fractures from 1.6 to 3.8 (95% CI 1.8 to 2.8) per 1000 arthroplasties, and it increased from 0.4 to 1.7 (95% CI 2.4 to 4.4) for periprosthetic distal femur fractures between 2004 and 2016. The mean population-based incidence of periprosthetic proximal femur fractures per 100,000 person-years was 5.3 ± 2.2 (95% CI 4.1 to 6.4) per year, and for periprosthetic distal femur fractures, it was 3.4 ± 1.7 (95% CI 2.5 to 4.4). The incidence of periprosthetic proximal femur fractures related to 100,000 person-years increased from 3.2 to 8.9 (95% CI 3.9 to 6.6), while the incidence of periprosthetic distal femur fractures increased from 1.3 to 4.4 (95% CI 2.4 to 4.8) during the study period. The cumulative incidence of major complications after periprosthetic proximal femur fracture was 8.8% at 1 year (95% CI 5.1% to 13.6%) and 12.3% at 10 years (95% CI 7.5% to 18.4%), and after periprosthetic distal femur fracture, it was 7.4% at 1 year (95% CI 3.5% to 13.4%) and 9.3% at 10 years (95% CI 4.7% to 15.7%). The cumulative incidence of reoperation after periprosthetic proximal femur fracture was 10.5% at 1 year (95% CI 6.5% to 15.7%) and 13.5% at 10 years (95% CI 8.9% to 19.1%), and for periprosthetic distal femur fracture, it was 8.3% at 1 year (95% CI 4.1% to 14.5%) and 13.8% at 10% years (95% CI 7.8% to 21.4%). The cumulative incidence of death after periprosthetic proximal femur fracture was 8.2% at 1 year (95% CI 4.7% to 12.9%) and 47.3% at 10 years (95% CI 38.1% to 55.9%), and after periprosthetic distal femur fractures, it was 14.8% at 1 year (95% CI 8.8% to 22.2%) and 67.8% at 10 years (95% CI 56.3% to 76.9%). CONCLUSION The increased use of THA and TKA has led to an increase in the incidence of operatively treated periprosthetic fractures, which means there will be more revisions in the future. Older age, frailty of these patients, and often-complicated fracture patterns are related to a high rate of complications, reoperations, and mortality. Healthcare systems must prepare for a large increase in revisions for periprosthetic fracture, which are morbid events for patients and costly ones for healthcare systems. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Simo Miettinen
- Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
- Kuopio Musculoskeletal Research Unit, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Reijo Sund
- Kuopio Musculoskeletal Research Unit, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Health and Social Economics Unit, Department of Health and Social Care Systems, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Samuli Törmä
- Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Heikki Kröger
- Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
- Kuopio Musculoskeletal Research Unit, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Wall R, Syed F, Arastu M, Riemer B, Boutefnouchet T. Treatment of supracondylar periprosthetic femoral fractures with retrograde intramedullary nailing versus distal femoral plating: A systematic review and meta-analysis of current evidence. Orthop Traumatol Surg Res 2023; 109:103489. [PMID: 36442809 DOI: 10.1016/j.otsr.2022.103489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 05/18/2022] [Accepted: 07/13/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Supracondylar periprosthetic fractures, when amenable to fixation, can be treated by either retrograde intramedullary nailing (RIMN) or plating. There is paucity of evidence regarding the superiority of one fixation method over the other. This review aims to determine which fixation method leads to better functional outcomes and perioperative complications. HYPOTHESIS Superiority of intramedullary nailing in terms of fracture healing and surgical complications when compared to distal femoral plating. MATERIALS AND METHODS Using PRISMA guidelines, a systematic search was performed. Studies which reported comparative outcome data following the two interventions were included. Qualitative data analysis and narrative synthesis were reported. Pooled comparisons were conducted when similar quantifiable outcomes were reported in a minimum of three studies. RESULTS A total of 151 records were generated by the search. Eight studies met the eligibility criteria so were included in the final analysis. The studies comprised a total of 407 cases, with a follow up period ranging from 1 to 15 years. 252 cases were treated with plate fixation and 155 with RIMN. All studies were mitigated by heterogeneity and methodological limitations. The review showed marked variation in descriptive fracture classifications. Narrative data synthesis was conducted. Although guarded by the methodological limitations of individual studies, outcomes showed that mean time to union was equivalent; 5.88 months for RIMN compared to 6.75 months in plating, standardised mean difference=0.28 (95% CI -0.02-0.58). Similarly, no statistically significant differences were reported between RIMN and plating for deep infection (OR:1.41 95%CI 0.40-5.00) and revision surgery (OR: 0.74, 95%CI 0.39-1.41). DISCUSSION Clinical outcomes showed a tendency that favours intramedullary nailing; however, generalisation of results was not possible. Future priority must be awarded to higher quality research in the form of a collaborative multicentre observational studies to delineate appropriate major diagnostic categories, ultimately informing a large comparative trial using condition specific validated outcome measures. LEVEL OF EVIDENCE III, meta-analysis.
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Affiliation(s)
- Rosemary Wall
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK.
| | - Farhan Syed
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Mateen Arastu
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Bryan Riemer
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
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Al-Jabri T, Ridha M, McCulloch RA, Jayadev C, Kayani B, Giannoudis PV. Periprosthetic distal femur fractures around total knee replacements: A comprehensive review. Injury 2023; 54:1030-1038. [PMID: 36854630 DOI: 10.1016/j.injury.2023.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
With a growing number of patients undergoing total knee replacements globally, coupled with an elderly population, the incidence of periprosthetic fractures around total knee replacements is increasing. As such, this is a highly topical subject that is gaining increasing interest within the orthopaedic community. This review provides a narrative synthesis of the most contemporary literature regarding distal femoral periprosthetic fractures. We review the related epidemiology, initial patient evaluation, the evolution and relevance of the classification systems and treatment options, particularly related to endoprosthetics and hybrid fixation constructs. The latest orthopaedic evidence related to this topic has been included.
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Affiliation(s)
- Talal Al-Jabri
- Trauma and Orthopaedic Surgery, Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; Joint Reconstruction Unit, The Royal National Orthopaedic Hospital, London, Stanmore HA7 4LP, UK; King Edward VII's Hospital, 5-10 Beaumont Street, Marylebone, London W1G 6AA, UK.
| | - Mohamed Ridha
- Joint Reconstruction Unit, The Royal National Orthopaedic Hospital, London, Stanmore HA7 4LP, UK
| | - Robert Allan McCulloch
- Joint Reconstruction Unit, The Royal National Orthopaedic Hospital, London, Stanmore HA7 4LP, UK
| | - Chethan Jayadev
- Joint Reconstruction Unit, The Royal National Orthopaedic Hospital, London, Stanmore HA7 4LP, UK; King Edward VII's Hospital, 5-10 Beaumont Street, Marylebone, London W1G 6AA, UK
| | - Babar Kayani
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London NW1 2BU, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, Leeds LS1 3EX, UK; NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
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10
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Laubach LK, Sharma V, Krumme JW, Larkin K, Satpathy J. Novel classification system for periprosthetic distal femoral fractures: a consideration for comminution. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-022-03468-9. [PMID: 36635567 DOI: 10.1007/s00590-022-03468-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE Comminution is an aspect of periprosthetic distal femoral fractures (PDFFs) that can influence postoperative outcomes and treatment selection, but is not included in current classification systems. We propose a new classification system for PDFFs based on comminution and cortical reads. This study aims to prove its reliability and efficacy to predict fracture severity and guide treatment. METHODS A retrospective chart review of patients treated with single or dual locking plates for PDFFs was performed. Two fellowship-trained orthopedic joint reconstruction specialists used available imaging to classify each PDFF as either type 1 (minimal or no comminution allowing for reconstruction of medial and lateral cortices), type 2 (comminution reasonably allowing for reconstruction of either medial or lateral cortex), and type 3 (extensive comminution not allowing reasonable reconstruction of medial or lateral cortex). Each PDFF was then analyzed for radiographic outcomes including lateral distal femoral angle (LDFA) and the posterior distal femoral angle (PDFA). RESULTS Interobserver reliability assessed by Cohen's Kappa statistic was 0.707, and average intraobserver reliability was 0.843, showing substantial reliability. Type 3 PDFFs had greater varus deformity than type 1 (p = 0.0457) or 2 (0.0198). CONCLUSION The proposed classification system accounts for comminution, demonstrates strong interobserver and intraobserver reliability, and can be used to guide treatment in regard to single versus dual plating. LEVEL OF EVIDENCE Retrospective comparative study, Level IV.
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Affiliation(s)
- Logan K Laubach
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, PO Box 980153, Richmond, VA, 23298, USA
| | - Viraj Sharma
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, PO Box 980153, Richmond, VA, 23298, USA
| | - John W Krumme
- KC Orthopedic Alliance, UMKC, 3651 College Blvd, Leawood, KS, 66211, USA
| | - Kevin Larkin
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, PO Box 980153, Richmond, VA, 23298, USA
| | - Jibanananda Satpathy
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, PO Box 980153, Richmond, VA, 23298, USA.
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11
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Watanabe N, Miyatake K, Takada R, Ogawa T, Amano Y, Jinno T, Koga H, Yoshii T, Okawa A. The prevalence and treatment of osteoporosis in patients undergoing total hip arthroplasty and the levels of biochemical markers of bone turnover. Bone Joint Res 2022; 11:873-880. [PMID: 36464500 PMCID: PMC9792872 DOI: 10.1302/2046-3758.1112.bjr-2022-0252.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
AIMS Osteoporosis is common in total hip arthroplasty (THA) patients. It plays a substantial factor in the surgery's outcome, and previous studies have revealed that pharmacological treatment for osteoporosis influences implant survival rate. The purpose of this study was to examine the prevalence of and treatment rates for osteoporosis prior to THA, and to explore differences in osteoporosis-related biomarkers between patients treated and untreated for osteoporosis. METHODS This single-centre retrospective study included 398 hip joints of patients who underwent THA. Using medical records, we examined preoperative bone mineral density measures of the hip and lumbar spine using dual energy X-ray absorptiometry (DXA) scans and the medications used to treat osteoporosis at the time of admission. We also assessed the following osteoporosis-related biomarkers: tartrate-resistant acid phosphatase 5b (TRACP-5b); total procollagen type 1 amino-terminal propeptide (total P1NP); intact parathyroid hormone; and homocysteine. RESULTS The prevalence of DXA-proven hip osteoporosis (T-score ≤ -2.5) among THA patients was 8.8% (35 of 398). The spinal osteoporosis prevalence rate was 4.5% (18 of 398), and 244 patients (61.3%; 244 of 398) had osteopenia (-2.5 < T-score ≤ -1) or osteoporosis of either the hip or spine. The rate of pharmacological osteoporosis treatment was 22.1% (88 of 398). TRACP-5b was significantly lower in the osteoporosis-treated group than in the untreated group (p < 0.001). CONCLUSION Osteoporosis is common in patients undergoing THA, but the diagnosis and treatment for osteoporosis were insufficient. The lower TRACP-5b levels in the osteoporosis-treated group - that is, osteoclast suppression - may contribute to the reduction of the postoperative revision rate after THA.Cite this article: Bone Joint Res 2022;11(12):873-880.
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Affiliation(s)
- Naoto Watanabe
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan, Naoto Watanabe. E-mail:
| | - Kazumasa Miyatake
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryohei Takada
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takahisa Ogawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yusuke Amano
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuya Jinno
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan,Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
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12
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Delsmann MM, Schmidt C, Mühlenfeld M, Jandl NM, Boese CK, Beil FT, Rolvien T, Ries C. Prevalence of osteoporosis and osteopenia in elderly patients scheduled for total knee arthroplasty. Arch Orthop Trauma Surg 2022; 142:3957-3964. [PMID: 34919186 PMCID: PMC9596583 DOI: 10.1007/s00402-021-04297-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 11/30/2021] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Maximilian M Delsmann
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany
| | - Constantin Schmidt
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany
| | - Moritz Mühlenfeld
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Nico Maximilian Jandl
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christoph Kolja Boese
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Frank Timo Beil
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Christian Ries
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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13
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Mazur M, Beyer J, Elsamaloty M, Patel D, Liu J, Ebraheim NA. Surgical outcomes of periprosthetic distal femur fractures after total knee arthroplasty classified by Su et al. system. J Orthop 2022; 34:260-265. [PMID: 36148178 PMCID: PMC9486061 DOI: 10.1016/j.jor.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/26/2022] [Accepted: 09/07/2022] [Indexed: 11/21/2022] Open
Abstract
Background Periprosthetic fractures of the distal femur remain a challenge to treat due to variations in both patient- and fracture-specific factors. This study was designed to analyze the outcomes of different subtypes of periprosthetic distal femur fractures based on the Su et al. classification system. Methods Thirty-six patients were classified with Su et al. system. All Type I and II fractures were managed with a locking plate. Most Type III fractures were managed with locking plate, while two were managed with long-stem revision arthroplasty due to evidence of implant loosening. Outcomes were measured and analyzed based on healing time, revision rate, and complication rate. Results Of the 36 patients, 30 (83.3%) achieved acceptable fracture union, while the remaining 6 (16.7%) experienced either delayed union or non-union. Type I fractures showed a significantly lower healing time than Type II and III fractures managed by locking plate. Delayed union was present in the Type II group, while non-union was recorded for two Type III fractures. Need for revision was more prevalent in fracture Types II and III. Conclusion The Su et al. system of classification for periprosthetic fractures of the distal femur matches the clinical outcomes of this study and would seem to be useful in the approach to the treatment of these fractures. The majority of these fractures can be managed with locking plate with reasonable results. However, if the implant is loosened in Type III fractures, revision arthroplasty is suggested.
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Affiliation(s)
- Matthew Mazur
- The University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH, 43614, USA
| | - Julia Beyer
- The University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH, 43614, USA
| | - Mazzin Elsamaloty
- The University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH, 43614, USA
| | - Devon Patel
- The University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH, 43614, USA
| | - Jiayong Liu
- The University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH, 43614, USA
| | - Nabil A. Ebraheim
- The University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH, 43614, USA
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14
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Kim JH, Kim KI, Park KC, Shon OJ, Sim JA, Kim GB. New Classification for Periprosthetic Distal Femoral Fractures Based on Locked-Plate Fixation Following Total Knee Arthroplasty: A Multicenter Study. J Arthroplasty 2022; 37:966-973. [PMID: 35121090 DOI: 10.1016/j.arth.2022.01.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/18/2022] [Accepted: 01/22/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study aimed to establish a new classification using locked-plate fixation for periprosthetic distal femoral fracture (PDFF) following total knee arthroplasty (TKA) and to determine when dual locked-plate fixation is necessary through defining this classification. METHODS One-hundred fifteen consecutive PDFFs that underwent operative treatment were reviewed from 2011 to 2019 with minimum 1-year follow-up. Most PDFFs were fixed with single or dual locked-plate fixations using the minimally invasive plate osteosynthesis technique. Based on preoperative radiographs, PDFFs were classified according to the level of main fracture line relative to the anterior flange of femoral component: type I and II, main fracture line located proximal and distal to the anterior flange; and type III, component instability regardless of fracture line requiring revisional TKA. Furthermore, type II fractures were subclassified based on the direction of fracture beak as follows: type IIL, lateral-beak; type IIM, medial-beak. The incidence, treatment methods, and complications were analyzed according to the classification. RESULTS Incidences of type I, IIL, IIM, and III were 64.4%, 8.7%, 24.3%, and 2.6%, respectively. Meanwhile, most PDFFs in type I and II were treated with lateral single locked-plate fixations, except for type IIM, which was treated with either single or dual locked-plate fixations. Overall complications were significantly higher in type II (28.9%) than in type I (10.8%, P = .019). In type IIM, bone union-related complications were significantly higher in single locked-plate fixation (50.0%) than in dual locked-plate fixation (5.6%; P = .013). CONCLUSION The new classification provides practical and obvious strategies for the treatment of PDFF following TKA using locked-plate fixation. For type IIM fracture, dual plate fixation is necessary to prevent fixation failure or nonunion.
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Affiliation(s)
- Jun-Ho Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Kang-Il Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases, Kyung Hee University Hospital at Gangdong, Seoul, Korea; Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Ki Chul Park
- Department of Orthopaedic Surgery, Hanyang University Guri Hospital, Gyeonggi-do, Korea
| | - Oog-Jin Shon
- Department of Orthopaedic Surgery, Yeungnam University Medical Center, Daegu, Korea
| | - Jae Ang Sim
- Department of Orthopaedics Surgery, Gachon University College of Medicine, Incheon, Korea
| | - Gi Beom Kim
- Department of Orthopaedic Surgery, Yeungnam University Medical Center, Daegu, Korea
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15
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Finzi SS, Berdini M, Carola D, Lattanzi G, Orabona G, Pascarella R, Gigante AP, Cerbasi S. Treatment of periprosthetic supracondylar fractures after CR total knee arthroplasty with retrograde intramedullary nailing in an elderly population: a long term evaluation. Orthop Rev (Pavia) 2022; 14:33978. [DOI: 10.52965/001c.33978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/24/2021] [Indexed: 11/06/2022] Open
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16
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Rubinger L, Khalik HA, Gazendam A, Wolfstadt J, Khoshbin A, Tushinski D, Johal H. Very Distal Femoral Periprosthetic Fractures: Replacement Versus Fixation: A Systematic Review. J Orthop Trauma 2021; 35:573-583. [PMID: 33993176 DOI: 10.1097/bot.0000000000002080] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To synthesize all-cause reoperations and complications data as well as secondary clinical and functional outcomes, after the management of very distal femur periprosthetic fractures (vDFPFs) in a geriatric patient population with either a distal femoral locking plate (DFLP) or distal femoral replacement (DFR). DATA SOURCES MEDLINE, Embase, and Web of Science were searched for English language articles from inception to March 16, 2020, in accordance to the PRISMA guidelines. STUDY SELECTION Studies reporting the management of vDFPFs in adults older than 65 years with either a DFLP or DFR were included. To ensure this review solely focused on very distal femoral periprosthetic fractures, only fractures of the following classifications were included: (1) Lewis and Rorabeck type II or III, (2) Su and Associates' Classification of Supracondylar Fractures of the Distal Femur type III, (3) Backstein et al type F2, and/or (4) Kim et al type II or III. DATA EXTRACTION Three reviewers independently extracted data from the included studies. Study validity was assessed using the methodological index for nonrandomized studies (MINORS), a quality assessment tool for nonrandomized controlled studies in surgery. DATA SYNTHESIS Twenty-five studies with 649 vDFPFs were included for analysis. There were 440 knees in the DFLP group (mean age range: 65.9-88.3 years) and 209 knees in the DFR group (mean age range: 71.0-84.8 years). Because of the literature's heterogeneity, the data were qualitatively synthesized. CONCLUSIONS vDFPFs in the elderly treated with DFR underwent fewer reoperations relative to DFLP (0%-45% vs. 0%-77%, respectively). Time to weight-bearing was observably shorter in DFR studies relative to DFLP studies. Functional outcomes and postoperative range of motion indicated a trend for DFLP knees to outperform DFR knees. Future research should include prospective studies and cost-effectiveness evaluations to better understand the utility of DFR for these fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Luc Rubinger
- Division of Orthopaedic Surgery, Center for Evidence Based Orthopaedics, McMaster University, Hamilton, ON, Canada
| | - Hassaan Abdel Khalik
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Aaron Gazendam
- Division of Orthopaedic Surgery, Center for Evidence Based Orthopaedics, McMaster University, Hamilton, ON, Canada
| | - Jesse Wolfstadt
- Granovsky Gluskin Division of Orthopedic Surgery, Sinai Health System, University of Toronto, Toronto, ON, Canada; and
| | - Amir Khoshbin
- Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Daniel Tushinski
- Division of Orthopaedic Surgery, Center for Evidence Based Orthopaedics, McMaster University, Hamilton, ON, Canada
| | - Herman Johal
- Division of Orthopaedic Surgery, Center for Evidence Based Orthopaedics, McMaster University, Hamilton, ON, Canada
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Fujii M, Kitamura K, Ikemura S, Hamai S, Motomura G, Nakashima Y. Pneumatic femoral broaching decreases post-operative subsidence of a cementless taper-wedge stem. INTERNATIONAL ORTHOPAEDICS 2021; 46:233-240. [PMID: 34448924 DOI: 10.1007/s00264-021-05196-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/15/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Stem subsidence is a known cause of early failure in cementless total hip arthroplasty (THA). The aim of this study was to determine the usefulness of pneumatic femoral broaching in preventing post-operative subsidence of a proximally porous-coated, taper-wedge stem. METHODS We reviewed 169 cases of primary THA with a single taper-wedge stem. Eighty THAs performed using pneumatic broaching were compared with 89 THAs performed using manual broaching in terms of postoperative canal fill ratio (CFR) at three levels, stem subsidence at one year post-operation, and stem fixation at latest follow-up (median, 24 months). RESULTS The median CFRs were higher in the pneumatic group than in the manual group at all levels (p < 0.05). The median stem subsidence at one year after THA was lower in the pneumatic group than in the manual group (0.2 mm vs. 0.6 mm, p = 0.007). A multivariate analysis determined a decreased CFR at 60 mm below the lesser trochanter and the manual broaching as independent factors affecting post-operative stem subsidence. At the latest follow-up, all stems showed stable fixation by bone ingrowth in both groups. CONCLUSION Our results showed that the pneumatic broaching device was useful in maximizing the mediolateral canal filling and initial stability and minimizing the subsidence of taper-wedge stems.
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Affiliation(s)
- Masanori Fujii
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi. Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Kenji Kitamura
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi. Higashi-ku, Fukuoka, 812-8582, Japan
| | - Satoshi Ikemura
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi. Higashi-ku, Fukuoka, 812-8582, Japan
| | - Satoshi Hamai
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi. Higashi-ku, Fukuoka, 812-8582, Japan
| | - Goro Motomura
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi. Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi. Higashi-ku, Fukuoka, 812-8582, Japan
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18
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Haider T, Hanna P, Mohamadi A, Merchan N, McNichol M, Wixted JJ, Appleton PT, Nazarian A, von Keudell AG, Rodriguez EK. Revision Arthroplasty Versus Open Reduction and Internal Fixation of Vancouver Type-B2 and B3 Periprosthetic Femoral Fractures. JBJS Rev 2021; 9:01874474-202108000-00009. [PMID: 34415859 DOI: 10.2106/jbjs.rvw.21.00008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Revision arthroplasty (RA) continues to be considered the gold standard in the surgical treatment of Vancouver type-B2 and B3 periprosthetic femoral fractures. However, open reduction and internal fixation (ORIF) has been associated with satisfactory outcomes. Thus, there is an ongoing discussion regarding the optimal surgical strategy for the treatment of these fractures. » In this systematic review and meta-analysis, no significant differences in clinical and radiographic outcome were observed between ORIF and RA in the treatment of Vancouver type-B2 periprosthetic femoral fractures. » ORIF of Vancouver type-B3 periprosthetic femoral fractures was associated with higher revision and reoperation rates than those after RA. » Compared with RA, a significantly higher rate of subsidence was found in the ORIF group in Vancouver type-B2 periprosthetic femoral fractures whereas no significant difference in terms of loosening was observed. » In the comparison of RA and ORIF for the treatment of Vancouver type-B2 and B3 fractures, the percentage of patients achieving full weight-bearing did not differ significantly. » Mortality rates did not differ between RA and ORIF in the treatment of Vancouver type-B2 and B3 fractures. » Overall complication rates did not differ between RA and ORIF in the treatment of Vancouver type-B2 and B3 fractures. » We found a high heterogeneity in applied surgical and fixation techniques in the ORIF group.
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Affiliation(s)
- Thomas Haider
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Philip Hanna
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Amin Mohamadi
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Nelson Merchan
- Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
- Harvard Medical School Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts
| | - Megan McNichol
- Knowledge Services Information Systems, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - John J Wixted
- Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
- Harvard Medical School Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts
| | - Paul T Appleton
- Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
- Harvard Medical School Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts
| | - Ara Nazarian
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
- Harvard Medical School Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
| | - Arvind G von Keudell
- Harvard Medical School Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward K Rodriguez
- Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
- Harvard Medical School Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts
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19
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Cinotti G, Sinno E, Fornara G, LaTorre G, Giannicola G. Plain films are not accurate in planning internal fixation in vancouver type B1 periprosthetic femoral fractures and in distinguishing between subtypes B1 And B2. Injury 2021; 52:1592-1596. [PMID: 33386158 DOI: 10.1016/j.injury.2020.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 11/05/2020] [Accepted: 12/16/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND While few studies analysed the diagnostic validity of preoperative radiographs in distinguishing between Vancouver type B1 and B2 periprosthetic femoral fractures (PFFs), no investigation has been conducted to assess the degree of diagnostic validity of preoperative radiographs in identifying the fracture course and planning the most appropriate treatment. We analysed the diagnostic validity of radiographs in detecting the fracture course and stem stability in Vancouver type B PFFs. METHODS Vancouver type B PFFs with different fracture courses were randomly performed in 36 dried cadaveric femurs in which a femoral broach had previously been implanted. Radiographic images, taken in the coronal and sagittal views, were analysed by 5 orthopaedic surgeons and 2 radiologists who were asked to reproduce the fracture course and to evaluate stem stability. A scoring system was used to determine the injured femoral cortex correctly identified by the examiners. RESULTS The identification of the fracture course was scored as poor in 52.4% and 56.%, fair in 23% and 23.4% and good in 24.6% and 19.8%, The identification of the fracture course in the coronal and axial vies radiographs was scored in coronal and axial view radiographs respectively. There was no significant difference in the average score obtained by senior and young examiners. In the coronal plane, the fracture course was poorly identified by all examiners in 11 (30.5%) femurs and by 5 or more examiners in 17 (47%). The fracture course was correctly identified by 5 or more examiners in 8 femurs (22%). A vertical fracture involving an emidiaphysis was found in 8 of the 11 femurs in which the PFF was poorly diagnosed by all examiners. Stem instability was correctly diagnosed in 45% of cases. CONCLUSIONS In type B PFFs preoperative radiographs show a reduced diagnostic validity in identifying the fracture course and, hence, in planning a correct treatment. Potentially unstable vertical fractures involving an emidiaphysis are likely to be poorly diagnosed since most of the fracture course is hidden by the femoral stem. In cementless stems the diagnostic validity of radiographs in diagnosing between Vancouver type B1 and B2 seems to be lower than that reported for cemented stems.
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Affiliation(s)
- Gianluca Cinotti
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences University "La Sapienza", Piazzale Aldo Moro, Rome 5 00185, Italy.
| | - Ennio Sinno
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences University "La Sapienza", Piazzale Aldo Moro, Rome 5 00185, Italy
| | - Gianluca Fornara
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences University "La Sapienza", Piazzale Aldo Moro, Rome 5 00185, Italy
| | - Giuseppe LaTorre
- Department of Public Health and Infectious Diseases, University "La Sapienza", Piazzale Aldo Moro, Rome 5 00185, Italy.
| | - Giuseppe Giannicola
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences University "La Sapienza", Piazzale Aldo Moro, Rome 5 00185, Italy
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20
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Shen J, Zhang Y, Yu G, Ji W. Multiple failures of internal fixation for treatment of periprosthetic femoral refracture: a case report and literature review. J Int Med Res 2021; 48:300060520958972. [PMID: 33292047 PMCID: PMC7727066 DOI: 10.1177/0300060520958972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We herein report a case involving three failures of internal fixation after periprosthetic femoral fracture (Vancouver type B1). The patient had low bone mass (T-score of −1.7) and was overweight (body mass index of 28.7 kg/m2) but had no sign of femoral stem loosening. The first open reduction with internal fixation was performed according to the recommended treatment. Unexpectedly, three treatment failures subsequently occurred, after which the patient finally attained endurable walking activity. A literature review indicated that the intrinsic biomechanical problems of Vancouver B1 fractures have not been thoroughly addressed. Choosing the correct surgical strategy for Vancouver B1 fractures is essential to avoid complications and ensure healing. A sufficient locking plate and cable system should be used after the first failure if revision was not performed the first time.
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Affiliation(s)
- Jing Shen
- Orthopedics Department, The First Affiliated Hospital of Zhejiang Chinese Medical University, HangZhou, ZheJiang, P.R. China
| | - Yang Zhang
- Traditional Chinese Medical hospital of Zhuji, Zhejiang province, China
| | | | - Weifeng Ji
- Orthopedics Department, The First Affiliated Hospital of Zhejiang Chinese Medical University, HangZhou, ZheJiang, P.R. China
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21
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Khwaja A, Mahoney W, Johnson J, Trompeter A, Lowe J. Biomechanics of periprosthetic femur fractures and early weightbearing. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:861-869. [PMID: 33852066 DOI: 10.1007/s00590-021-02969-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The incidence of periprosthetic fractures is expected to rise increase by 4.6% every 10 years between 2015 and 2060. There are few large series examining optimal fixation constructs or the influence of early ambulation on outcome. The purpose of this narrative review is to investigate the published biomechanical considerations for periprosthetic fracture fixation, with specific consideration of early postoperative weightbearing. METHODS A literature review was performed to identify fracture incidences, etiology, and current trends in weightbearing after fixation. Benefits of early weightbearing, current constructs, and biomechanics are reviewed. RESULTS The limited data available support medical benefits and increased union rates with early mobilization. Optimal fixation constructs are not agreed upon, but mechanical studies suggest that dual implant constructs can support physiologic weightbearing loads. CONCLUSION Further clinical trials are required to investigate fracture union and hardware complications in dual implant construct.
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Affiliation(s)
- Ansab Khwaja
- Department of Orthopaedics, University of Arizona, 1625 N Campbell Avenue, Tucson, AZ, 85719, USA.
| | - William Mahoney
- Department of Orthopaedics, University of Arizona, 1625 N Campbell Avenue, Tucson, AZ, 85719, USA
| | - Jay Johnson
- Department of Orthopaedics, University of Arizona, 1625 N Campbell Avenue, Tucson, AZ, 85719, USA.,Banner University Medical Group, Banner Health System Phoenix, Phoenix, AZ, USA
| | | | - Jason Lowe
- Department of Orthopaedics, University of Arizona, 1625 N Campbell Avenue, Tucson, AZ, 85719, USA.,Banner University Medical Group, Banner Health System Phoenix, Phoenix, AZ, USA
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22
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Maggs JL, Swanton EW, Hubble MJ, Wilson MJ. Mind the gap! The Lucent Line Sign: A Pathognomonic Radiographic Finding in Periprosthetic Hip Fractures Around Cemented Polished Tapered Femoral Stems. J Orthop Case Rep 2021; 11:33-36. [PMID: 34327161 PMCID: PMC8310649 DOI: 10.13107/jocr.2021.v11.i04.2140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Diagnosing minimally displaced femoral PPFs using plain-film radiographs can be challenging. As a result, fractures can be missed. Case Report: We present four cases of minimally displaced PPFs around cemented polished tapered stems. In each case, radiographs demonstrate no clear cortical breach, but the presence of a fracture is highlighted by a pathognomic lucent line between the cement mantle and the prosthesis: The Lucent Line Sign. Conclusion: Paying attention to the Lucent Line Sign can be pivotal in the diagnosis of minimally displaced PPFs around cemented polished tapered stems.
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Affiliation(s)
- Joanna L Maggs
- Department of Orthopaedics, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Eric W Swanton
- Department of Orthopaedics, Waitemata District Health Board, Auckland, New Zealand
| | - Matthew Jw Hubble
- Department of Orthopaedics, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Matthew J Wilson
- Department of Orthopaedics, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, United Kingdom
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23
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Mühlenfeld M, Strahl A, Bechler U, Jandl NM, Hubert J, Rolvien T. Bone mineral density assessment by DXA in rheumatic patients with end-stage osteoarthritis undergoing total joint arthroplasty. BMC Musculoskelet Disord 2021; 22:173. [PMID: 33573628 PMCID: PMC7879515 DOI: 10.1186/s12891-021-04039-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/18/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Patients with rheumatic diseases have a high risk for joint destruction and secondary osteoarthritis (OA) as well as low bone mineral density (BMD, i.e., osteoporosis). While several factors may lead to low BMD in these patients, the value of BMD measurements in rheumatic patients with end-stage OA scheduled for total joint arthroplasty is unknown. METHODS In this retrospective cross-sectional study of 50 adults with secondary OA due to rheumatic diseases, we evaluated dual energy X-ray absorptiometry (DXA) measurements of both hips and the spine performed within 3 months prior to arthroplasty (n = 25 total hip arthroplasty, THA; n = 25 total knee arthroplasty, TKA). We analyzed various demographic and disease-specific characteristics and their effect on DXA results by using group comparisons and multivariate linear regression models. RESULTS Although patients undergoing TKA were younger (63.2 ± 14.2 vs. 71.0 ± 10.8 yr., p = 0.035), osteoporosis was observed more frequently in patients scheduled for TKA than THA (32% vs. 12%). Osteopenia was detected in 13/25 patients (52%) in both the THA and TKA cohort. In the THA cohort, female sex, lower BMI and prednisolone use were associated with lower T-score in the hip. In TKA patients, higher OA grade determined by Kellgren-Lawrence score was associated with lower T-score in the hip of the affected side. CONCLUSIONS Osteoporosis is present in a considerable frequency of rheumatic patients with end-stage OA, and THA and TKA patients show distinct frequencies and risk factors of low BMD. Our findings point to a potential value of DXA regarding preoperative evaluation of bone status.
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Affiliation(s)
- Moritz Mühlenfeld
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - André Strahl
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Ulrich Bechler
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Nico Maximilian Jandl
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.,Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Jan Hubert
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Tim Rolvien
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany. .,Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany.
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24
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Toner E, Khaled A, Ramesh A, Qureshi MK, Al Suyyagh K, Dunkow P. Financial Impact of Inaccurate Coding Plus Cost-Effectiveness Analysis for Surgically Managed Patients With Periprosthetic Fractures. Cureus 2021; 13:e13060. [PMID: 33680602 PMCID: PMC7929546 DOI: 10.7759/cureus.13060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background An upward trend is seen in a number of periprosthetic fractures. Their management often requires complex surgical intervention, expert skills and expensive equipment. Hospitals get paid according to Healthcare Resource Group (HRG) tariffs. HRG gets generated once diagnoses, Charlson comorbidity (CC) index score, surgical procedures, investigations and length of stay have been coded for. Coding departments consist of non-clinicians. Although auditing systems are in and made of internal and external auditors, we hypothesized that multiple errors can still occur which may result in significant financial losses. Objectives To assess the accuracy of coding for management of periprosthetic fractures. To identify causes for inaccurate coding and assess the financial impact of highly complex trauma in a district general hospital (DGH). Methods Retrospective comparative analysis of case notes for patients with an M966 diagnosis code (periprosthetic fracture) between 1st November 2017 and 1st November 2018. All cases were analysed and data for primary procedure, primary diagnosis, secondary procedures and secondary diagnosis, comorbidities and length of stay were extrapolated and re-coded using the same software in use by the coding team. Costs incurred for each surgically managed patient were calculated using a rough estimate of cost of each procedure. Finally, cost-effectiveness analysis was carried out by comparing our calculated figures to the actual final claim by our institution. Results Twenty-nine patients with the diagnosis of periprosthetic fracture were identified by the coding team using M966 code. A further case was identified by reviewing operating software (Operating Room Management Information System [ORMIS®]). In four cases (13.3 %), the primary diagnosis was coded incorrectly by the coding team. Overall coders accuracy for surgically managed patients (n=21) was 52% (n=11). This resulted in an estimated incurred loss of £25,000. Wrong/omitted site of surgery was found to be the most influential coder error with up to £8000 loss in one case (P<0.05). Cost-effectiveness analysis demonstrated the stark differences in costs for HRG tariffs when used in trauma setting vs non-trauma setting. Open reduction and internal fixation (ORIF) was associated with less financial loss to our trust with closer procedural costs to HRG tariff (average cost of £9200 for ORIF vs £22,030 for a massive endoprosthesis). Conclusions Surgeons should carefully review codes for such complex procedures before or soon after surgery. Wrong/omitted site of surgery is the key cause for losses in our cohort, followed by inadequate recording of comorbidities. Coders can only code for what is documented. Following cost-effectiveness analysis our study highlights the need for HRG tariffs to be revised for such procedures. The cost of ORIF vs massive endoprosthesis should be noted, signifying the implant costs when such specialised revision surgery performed over less expensive ORIF surgery.
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Affiliation(s)
- Ethan Toner
- Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, GBR
| | - Ahmad Khaled
- Trauma and Orthopaedics, Blackpool Victoria Hospital, Blackpool, GBR
| | - Ashwanth Ramesh
- Trauma and Orthopaedics, Lancaster General Hospital, Lancaster, GBR
| | - Mobeen K Qureshi
- Trauma and Orthopaedics, Blackpool Victoria Hospital, Blackpool, GBR
| | | | - Paul Dunkow
- Trauma and Orthopaedics, Blackpool Victoria Hospital, Blackpool, GBR
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25
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Maggs JL, Swanton E, Whitehouse SL, Howell JR, Timperley AJ, Hubble MJW, Wilson MJ. B2 or not B2? That is the question: a review of periprosthetic fractures around cemented taper-slip femoral components. Bone Joint J 2021; 103-B:71-78. [PMID: 33380191 DOI: 10.1302/0301-620x.103b1.bjj-2020-0163.r1] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Periprosthetic fractures (PPFs) around cemented taper-slip femoral prostheses often result in a femoral component that is loose at the prosthesis-cement interface, but where the cement-bone interface remains well-fixed and bone stock is good. We aim to understand how best to classify and manage these fractures by using a modification of the Vancouver classification. METHODS We reviewed 87 PPFs. Each was a first episode of fracture around a cemented femoral component, where surgical management consisted of revision surgery. Data regarding initial injury, intraoperative findings, and management were prospectively collected. Patient records and serial radiographs were reviewed to determine fracture classification, whether the bone cement was well fixed (B2W) or loose (B2L), and time to fracture union following treatment. RESULTS In total, 47 B2W fractures (54.0%) and one B3 fracture (1.1%) had cement that remained well-fixed at the cement-bone interface. These cases were treated with cement-in-cement (CinC) revision arthroplasty. Overall, 43 fractures with follow-up united, and two patients sustained further fractures secondary to nonunion and required further revision surgery. A total of 19 B2L fractures (21.8%) and 19 B3 fractures (21.8%) had cement that was loose at the cement-bone interface. These cases were managed by revision arthroplasty with either cemented or uncemented femoral components, or proximal femoral arthroplasty. One case could not be classified. CONCLUSION We endorse a modification of the original Vancouver system to include a subclassification of B2 fractures around cemented femoral prostheses to include B2W (where cement is well-fixed to bone) and B2L (where the cement is loose). Fractures around taper-slip design stems are more likely to fracture in a B2W pattern compared to fractures around composite beam design stems which are more likely to fracture in a B2L pattern. B2W fractures can reliably be managed with CinC revision. Cite this article: Bone Joint J 2021;103-B(1):71-78.
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Affiliation(s)
- Joanna L Maggs
- Princess Elizabeth Orthopaedic Centre, Exeter, Devon, UK
| | - Eric Swanton
- Princess Elizabeth Orthopaedic Centre, Exeter, Devon, UK
| | - Sarah L Whitehouse
- Orthopaedic Research Unit, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | | | - A John Timperley
- Princess Elizabeth Orthopaedic Centre, Exeter, Devon, UK.,College of Engineering, Maths and Physical Science, University of Exeter, Exeter, Devon, UK
| | | | - Matt J Wilson
- Princess Elizabeth Orthopaedic Centre, Exeter, Devon, UK
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26
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Bissias C, Kaspiris A, Kalogeropoulos A, Papoutsis K, Natsioulas N, Barbagiannis K, Papagelopoulos PJ, Savvidou OD. Factors affecting the incidence of postoperative periprosthetic fractures following primary and revision hip arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res 2021; 16:15. [PMID: 33407704 PMCID: PMC7788804 DOI: 10.1186/s13018-020-02152-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Christos Bissias
- Department of Orthopaedic Surgery, Naval Hospital of Athens, Deinokratous 70, 115 21, Athens, Greece.
| | - Angelos Kaspiris
- Laboratory of Molecular Pharmacology/Division for Orthopaedic Research, School of Health Sciences, University of Patras, 26504, Patras, Greece
| | | | - Konstantinos Papoutsis
- Department of Orthopaedic Surgery, Naval Hospital of Athens, Deinokratous 70, 115 21, Athens, Greece
| | - Nikolaos Natsioulas
- Department of Orthopaedic Surgery, Naval Hospital of Athens, Deinokratous 70, 115 21, Athens, Greece
| | - Konstantinos Barbagiannis
- Department of Orthopaedic Surgery, Naval Hospital of Athens, Deinokratous 70, 115 21, Athens, Greece
| | - Panayiotis J Papagelopoulos
- 1st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, 124 62, Athens, Greece
| | - Olga D Savvidou
- 1st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, 124 62, Athens, Greece
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27
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Pagani NR, Varady NH, Chen AF, Rajaee SS, Kavolus JJ. Nationwide Analysis of Lower Extremity Periprosthetic Fractures. J Arthroplasty 2021; 36:317-324. [PMID: 32826143 DOI: 10.1016/j.arth.2020.07.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/08/2020] [Accepted: 07/20/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although the annual incidence of primary total joint arthroplasty is increasing, trends in the annual incidence of periprosthetic fractures have not been established. This study aimed to define the annual incidence of periprosthetic fractures in the United States. METHODS Inpatient admission data for 60,887 surgically treated lower extremity periprosthetic fractures between 2006 and 2015 were obtained from the National Inpatient Sample database. The annual incidence of periprosthetic fractures was defined as the number of new cases per year and presented as a population-adjusted rate per 100,000 US individuals. Univariable methods were used for trend analysis and comparisons between groups. RESULTS The national annual incidence of periprosthetic fractures presented as a population-adjusted rate of new cases per year peaked in 2008 (2.72; 95% confidence interval [95% CI], 2.39-3.05), remained stable from 2010 (1.65; 95% CI, 1.45-1.86) through 2013 (1.67; 95% CI, 1.55-1.8) and increased in 2014 (1.99; 95% CI, 1.85-2.13) and 2015 (2.47; 95% CI, 2.31-2.62). The proportion of femoral periprosthetic fractures managed with total knee arthroplasty revision remained stable (Ptrend = .97) with an increase in total hip arthroplasty (THA) revision (Ptrend < .001) and concurrent decrease in open reduction and internal fixation (ORIF) (Ptrend < .001). Revision THA was significantly more costly than revision total knee arthroplasty (P = .004), and both were significantly more costly than ORIF (P < .001 for both). CONCLUSION The annual incidence of periprosthetic fractures remained relatively stable throughout our study period. The proportion of periprosthetic fractures managed with revision THA increased, whereas ORIF decreased. Our findings are encouraging considering the significant burden an increase in periprosthetic fracture incidence would present to the health care system in terms of both expense and patient morbidity.
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Affiliation(s)
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sean S Rajaee
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joseph J Kavolus
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA
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28
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White R, Krueger D, De Guio F, Michelet F, Hans D, Anderson P, Binkley N. An Exploratory Study of the Texture Research Investigational Platform (TRIP) to Evaluate Bone Texture Score of Distal Femur DXA Scans - A TBS-Based Approach. J Clin Densitom 2021; 24:112-117. [PMID: 31358359 DOI: 10.1016/j.jocd.2019.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/18/2019] [Accepted: 06/25/2019] [Indexed: 11/21/2022]
Abstract
Poor bone status is associated with increased complications following orthopedic surgery. Therefore, assessing site-specific skeletal status prior to or after orthopedic surgery to optimize outcomes is appealing. The trabecular bone score (TBS) approach, a surrogate for microarchitecture, was adapted to the Texture Research Investigational Platform (TRIP), which allows assessment of many skeletal sites imaged by various modalities. TRIP generates a bone texture score (TBS ORTHO), which could potentially guide surgical decision-making and offer insight into postsurgical fracture risk. As distal femur bone loss occurs following total knee arthroplasty (TKA), we hypothesized that TBS ORTHO after TKA would identify poorer texture in the operated femur compared to the nonoperated. We evaluated 30 subjects (15 M/15 F) with unilateral TKA 2-5 yr previously, mean age 67.9 yr and body mass index 30 kg/m2. Using a Lunar iDXA, lumbar spine and entire femur scans were obtained, the latter using the atypical femur fracture feature. Distal femur bone mineral density (BMD) and TBS ORTHO were obtained using manual regions of interest (ROI) at 15% and 25% of leg length from the intercondylar notch. TBS ORTHO was determined using distal femur DICOM images and TRIP v1.0 (Medimaps, France). Differences in operated vs nonoperated femur were evaluated by paired t test. As previously reported, operated leg BMD was approx 10% lower at 15% and 25% ROIs. Similarly, TBS ORTHO values in the operated leg were approx 5% lower (p < 0.05) at these same ROIs. Distal femur TBS ORTHO and BMD were largely unrelated. TBS ORTHO reproducibility at these ROIs was approx 3.5%. In conclusion, this pilot study documents the feasibility of reproducibly obtaining distal femur TBS ORTHO values. Lower values were observed in the surgical leg, consistent with the bone loss that follows TKA. Further work is indicated to refine TRIP use and evaluate whether such data provides guidance for surgical decision-making and improves periprosthetic fracture prediction.
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Affiliation(s)
- R White
- University of Wisconsin, Osteoporosis Clinical Research Program, Madison, WI, USA.
| | - D Krueger
- University of Wisconsin, Osteoporosis Clinical Research Program, Madison, WI, USA
| | - F De Guio
- Research and Development Department, Medimaps, Bordeaux, France
| | - F Michelet
- Research and Development Department, Medimaps, Bordeaux, France
| | - D Hans
- Research and Development Department, Medimaps, Bordeaux, France; Center of Bone Diseases, Bone and Joint Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - P Anderson
- University of Wisconsin, Department of Orthopedics and Rehabilitation, Madison, WI, USA
| | - N Binkley
- University of Wisconsin, Osteoporosis Clinical Research Program, Madison, WI, USA
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29
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Ha CW, Park YB. Underestimation and undertreatment of osteoporosis in patients awaiting primary total knee arthroplasty. Arch Orthop Trauma Surg 2020; 140:1109-1114. [PMID: 32358659 DOI: 10.1007/s00402-020-03462-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Osteoporosis is generally regarded as a risk factor for periprosthetic fracture during or after primary total knee arthroplasty (TKA). Despite this, little is known about osteoporosis in patients undergoing elective primary TKA Therefore, we sought to investigate the prevalence of osteoporosis and rates of pharmacologic osteoporosis treatment prior to primary TKA. We hypothesized that preoperative osteoporosis is underestimated and undertreated in the primary TKA population. MATERIALS AND METHODS This retrospective study included consecutive 1972 patients scheduled for elective primary TKA at a single tertiary hospital (age, 50-89 years). Charts were reviewed for patient demographics, prior pharmacologic osteoporosis treatment and Knee Society (KS) scoring system and WOMAC score. Dual energy X-ray absorptiometry (DEXA) measurement of the lumbar vertebrae and proximal femur was performed in all patients on the day before surgery. The associations of BMD with age, sex, body mass index (BMI), and clinical outcome were analyzed. RESULTS The prevalence of osteoporosis was 50.0% (53.4% in women and 7.0% in men). Among patients with osteoporosis, only 15.1% (149/986) of patients (15.0% in women and 30.0% in men) had pharmacological osteoporosis treatment prior to primary TKA. Age, sex and WOMAC stiffness showed association with osteoporosis. Sex (odds ratio (OR): 20.83, p < 0.001) was the most significant factor associated with osteoporosis. CONCLUSION Osteoporosis was highly prevalent in patients awaiting TKA, but the rates of diagnosis and pharmacologic osteoporosis treatment were low. Therefore, more attention needs to estimate and treat osteoporosis in patients awaiting primary TKA, especially in female patients.
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Affiliation(s)
- Chul-Won Ha
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Yong-Beom Park
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea.
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Stoffel K, Horn T, Zagra L, Mueller M, Perka C, Eckardt H. Periprosthetic fractures of the proximal femur: beyond the Vancouver classification. EFORT Open Rev 2020; 5:449-456. [PMID: 32818072 PMCID: PMC7407870 DOI: 10.1302/2058-5241.5.190086] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The majority of periprosthetic femoral fractures are treated surgically. Surgical treatment may be revision only, revision in combination with open reduction and internal fixation (ORIF), or ORIF only. The treatment decision is dependent on whether the stem is loose or not, but loose stems are not always identified, resulting in unsatisfactory treatments. This article presents an algorithmic approach to identifying loose stems around proximal femoral periprosthetic fractures, taking patient history, stem design, and plain radiographs into consideration. This approach may help identifying loose stems and increase the probability of effective treatments.
Cite this article: EFORT Open Rev 2020;5:449-456. DOI: 10.1302/2058-5241.5.190086
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Affiliation(s)
- Karl Stoffel
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
| | - Tamara Horn
- Clinic of Orthopaedic Surgery, Kantonsspital Baselland, Liestal, Switzerland
| | - Luigi Zagra
- Hip Department, IRCCS Galeazzi Orthopaedic Institute, Milano, Italy
| | - Michael Mueller
- Orthopaedic Department, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Carsten Perka
- Orthopaedic Department, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Henrik Eckardt
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
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Terzini M, Aldieri A, Nurisso S, De Nisco G, Bignardi C. Finite Element Modeling Application in Forensic Practice: A Periprosthetic Femoral Fracture Case Study. Front Bioeng Biotechnol 2020; 8:619. [PMID: 32656199 PMCID: PMC7324477 DOI: 10.3389/fbioe.2020.00619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/20/2020] [Indexed: 11/13/2022] Open
Abstract
The incidence of periprosthetic fractures has rapidly increased in the last two decades and has been the cause of a large number of revision surgeries and permanent physical disability for many patients, as well as a significant socioeconomic burden for many nations. This research deals with a periprosthetic femur fracture real event, occurred following a total hip arthroplasty and treated with one of the most widespread internal fixation methods: the implant of a periprosthetic femur plate system. A Finite Element analysis was performed to investigate the implanted femur plate break after a short follow-up and to understand the plate break causes. Such events are currently object of forensic debate as more and more often hospitals, surgeons, and medical device manufacturers are denounced by patients to whom similar events occur. In this work, different load situations acting on the femur during daily and incidental activities were simulated, in order to validate the correct behavior of the plate, according to the intended use recommended by the manufacturer. The analysis demonstrates that the plate failure can occur in situations of unconventional loading such as that caused by stumbling and in presence of incomplete bone healing.
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Affiliation(s)
- Mara Terzini
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy.,PolitoBIOMed Lab, Politecnico di Torino, Turin, Italy
| | - Alessandra Aldieri
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy.,PolitoBIOMed Lab, Politecnico di Torino, Turin, Italy
| | - Stefania Nurisso
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy.,PolitoBIOMed Lab, Politecnico di Torino, Turin, Italy
| | - Giuseppe De Nisco
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy.,PolitoBIOMed Lab, Politecnico di Torino, Turin, Italy
| | - Cristina Bignardi
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy.,PolitoBIOMed Lab, Politecnico di Torino, Turin, Italy
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Saunders PRJ, Shaw DA, Sidharthan SK, Siney PD, Young SK, Board TN. Survivorship and Radiological Analysis of a Monoblock, Hydroxyapatite-Coated Titanium Stem in Revision Hip Arthroplasty. J Arthroplasty 2020; 35:1678-1685. [PMID: 32169384 DOI: 10.1016/j.arth.2020.01.081] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/17/2020] [Accepted: 01/30/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We evaluated the survivorship, incidence of complications, radiological subsidence, proximal stress shielding, and patient-reported outcomes of a conservative, monoblock, hydroxyapatite-coated femoral stem. METHODS This retrospective cohort study reports on 254 revision hip arthroplasties between January 2006 and June 2016. The mean age of patients was 71 years. The mean length of follow-up was 62 months (range 12-152). RESULTS There were 13 stem re-revisions: infection (4), periprosthetic fracture (4), aseptic stem loosening (3), stem fracture (1), and extended trochanteric osteotomy nonunion (1). Kaplan-Meier aseptic stem survivorship was 97.33% (confidence interval 94-100) at 6 years. There were 29 intraoperative fractures. There were 6 cases of subsidence greater than 10 mm; however, none required revision. Ninety-six percent of cases showed no proximal stress shielding. Thigh pain was reported in 3% of cases. CONCLUSION This study confirms that this stem provides good survivorship at 6 years, acceptable complication rates, adequate proximal bone loading, low incidences of thigh pain, and reliable clinical performance in revision hip arthroplasty. KEY MESSAGE A monoblock, fully hydroxyapatite-coated titanium stem is reliable in revision arthroplasty with mild-moderate femur deficiencies.
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Affiliation(s)
- Paul R J Saunders
- Department of Orthopaedics, Warwick Hospital, South Warwickshire NHS Foundation Trust, Warwick, United Kingdom
| | - Debbie A Shaw
- Wrightington Lower Limb Unit, Wrightington Centre for Hip Surgery, Wrightington Hospital, Wigan, United Kingdom
| | - Sijin K Sidharthan
- Wrightington Lower Limb Unit, Wrightington Centre for Hip Surgery, Wrightington Hospital, Wigan, United Kingdom
| | - Paul D Siney
- Wrightington Lower Limb Unit, Wrightington Centre for Hip Surgery, Wrightington Hospital, Wigan, United Kingdom
| | - Stephen K Young
- Department of Orthopaedics, Warwick Hospital, South Warwickshire NHS Foundation Trust, Warwick, United Kingdom
| | - Tim N Board
- Wrightington Lower Limb Unit, Wrightington Centre for Hip Surgery, Wrightington Hospital, Wigan, United Kingdom
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Benkovich V, Klassov Y, Mazilis B, Bloom S. Periprosthetic fractures of the knee: a comprehensive review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 30:387-399. [PMID: 31745642 PMCID: PMC7138771 DOI: 10.1007/s00590-019-02582-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 10/15/2019] [Indexed: 12/28/2022]
Abstract
Demographic changes have resulted in an increase in the number of older patients diagnosed with degenerative joint disease. Developments in the field of joint arthroplasty allow a broader population to improve their lifestyles. An increased demand for knee arthroplasty has led to a rise in operations performed worldwide. Although there has been a constant propagation of technology and an increase in medical staffing at a professional level, many patients still encounter complications. Though rare, these factors may lead to life-threatening scenarios and a devastating effect on the success of the operation. One such rare complication includes periprosthetic fractures around the knee, a complex injury which requires a cautious and experienced approach. In this review, we analyze the prevalence, risk factors and classification, investigation and treatment options for periprosthetic fractures with total knee arthroplasty.
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Affiliation(s)
- Vadim Benkovich
- Department of Joint Arthroplasty, “Yonatan” Center-Israeli Joint and Spine Health Center, Assuta Medical Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - Yuri Klassov
- Orthopedic Surgery Department, Soroka University Medical Center, Beer-Sheva, Israel
| | - Boris Mazilis
- Ben Gurion University, Soroka medical Center, Beer-Sheva, Israel
| | - Shlomo Bloom
- Orthopedic Surgery Department, Soroka University Medical Center, Beer-Sheva, Israel
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Extension of the Direct Anterior Approach for the Treatment of Periprosthetic Femoral Fractures. J Arthroplasty 2019; 34:2449-2453. [PMID: 31186184 DOI: 10.1016/j.arth.2019.05.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/26/2019] [Accepted: 05/08/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Periprosthetic femoral fractures (PFFs) after total hip arthroplasty are devastating complications often resulting in functional limitations and increased mortality. The use of the direct anterior approach (DAA) is becoming more popular, and the number of revisions done through this interval is increasing. The DAA interval can be expanded to treat PFFs. This retrospective case series assessed outcomes of PFF patients treated with the extension of the DAA interval. METHODS The study contained 40 patients (40 hips). Mean patient age was 74.3 years (range, 55.1-92.2 years). Mean follow-up time was 50.4 months (range, 20-98.2 months). Fractures were classified as Vancouver B2 (n = 36) and B3 (n = 4). RESULTS Median cut-to-close time was 152 minutes (interquartile range: 80-279). There were five complications (12.5%): 2 deaths, 1 transient femoral nerve palsy, 1 fissure distal to the stem, and 1 hematoma. CONCLUSION Expansion of the DAA interval to treat PFF showed similar results compared with other surgical approaches in terms of mortality, complications, fracture healing, and dislocation rate. These results indicate that femoral revision for PFF in the DAA interval is a safe and reliable procedure compared with other surgical approaches for the treatment of Vancouver B2 and B3 periprosthetic fractures.
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Baum C, Leimbacher M, Kriechling P, Platz A, Cadosch D. Treatment of Periprosthetic Femoral Fractures Vancouver Type B2: Revision Arthroplasty Versus Open Reduction and Internal Fixation With Locking Compression Plate. Geriatr Orthop Surg Rehabil 2019; 10:2151459319876859. [PMID: 31579528 PMCID: PMC6759715 DOI: 10.1177/2151459319876859] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/25/2019] [Accepted: 08/15/2019] [Indexed: 12/22/2022] Open
Abstract
Introduction: The Vancouver algorithm recommends revision arthroplasty (RA) for Vancouver type B2 (VTB2) fractures. However, open reduction and internal fixation (ORIF) using locking compression plates (LCP) may be a valid and less invasive alternative treatment. Materials and Methods: Between January 2007 and March 2017, we retrospectively recruited all patients treated with either ORIF with LCP or RA for VTB2 fractures in our clinic. All of the following were reviewed: the length of hospital stay, the operating time, the need for blood transfusions during and/or after surgery, implant-related and patient-related complications, need for revision surgery, and the radiological outcome. Additionally, the functional outcome was investigated. Results: Fifty-nine patients were recruited. Thirty-five (59.3%) patients underwent RA, while 24 (40.7%) patients received ORIF with LCP. The median surgical time was 137.50 minutes in the LCP group compared to 160.00 minutes in the RA group (P = .051). Three (12.5%) patients in the LCP group and 10 (28.6%) patients in the RA group experienced an implant-associated complication (P = .131). Patient-related complications occurred in 3 (12.5%) patients in the LCP group versus 6 (17.1%) patients in the RA group (P = .628). The mean preoperative Parker mobility score was 9 points in both groups and decreased in both groups to a mean of 5 points in the LCP and 7 points in the RA group. Discussion: Open reduction and internal fixation with LCP seems to be a less invasive procedure for VTB2 fractures in comparison to RA. It is a bone-sparing procedure that can be advantageous for further revision operations. Moreover, some fractures can only be anatomically reduced by ORIF with LCP, whereas for proximal fractures with a radiologically unambiguously loosened stem RA might be advantageous. Conclusion: In line with previously published studies, our data suggest that ORIF using LCP is a valid treatment option for VTB2 fractures.
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Affiliation(s)
- C Baum
- Department of General, Hand and Trauma Surgery, Triemli Hospital Zurich, Zurich, Switzerland
| | - M Leimbacher
- Department of General, Hand and Trauma Surgery, Triemli Hospital Zurich, Zurich, Switzerland
| | - P Kriechling
- Department of General, Hand and Trauma Surgery, Triemli Hospital Zurich, Zurich, Switzerland
| | - A Platz
- Department of General, Hand and Trauma Surgery, Triemli Hospital Zurich, Zurich, Switzerland
| | - D Cadosch
- Department of General, Hand and Trauma Surgery, Triemli Hospital Zurich, Zurich, Switzerland
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Bernatz JT, Brooks AE, Squire MW, Illgen RI, Binkley NC, Anderson PA. Osteoporosis Is Common and Undertreated Prior to Total Joint Arthroplasty. J Arthroplasty 2019; 34:1347-1353. [PMID: 30992237 DOI: 10.1016/j.arth.2019.03.044] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 03/11/2019] [Accepted: 03/14/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Osteoporosis is common in total joint arthroplasty (TJA) patients and likely contributes to the increasing incidence of periprosthetic fracture. Despite this, the prevalence of osteoporosis in patients undergoing elective TJA is inadequately studied. We hypothesize that preoperative osteoporosis is underrecognized and undertreated in the TJA population. The purpose of this study is to report preoperative osteoporosis screening rates and prevalence prior to TJA and rates of pharmacologic osteoporosis treatment in the TJA population. METHODS This is a retrospective case series of 200 consecutive adults (106F, 94M) aged 48-92 years who underwent elective TJA (100 total hip, 100 total knee) at a single tertiary-care center. Charts were retrospectively reviewed to determine preoperative osteoporosis risk factors, prior dual-energy X-ray absorptiometry (DXA) testing, and prior osteoporosis pharmacotherapy. Fracture risk was estimated using the Fracture Risk Assessment Tool and the National Osteoporosis Foundation criteria for screening and treatment were applied to all patients. RESULTS One hundred nineteen of 200 patients (59.5%) met criteria for DXA testing. Of these 119, 21 (17.6%) had DXA testing in the 2 years prior to surgery, and 33% had osteoporosis by T-score. Forty-nine patients (24.5%) met National Osteoporosis Foundation criteria for pharmacologic osteoporosis treatment, and 11 of these 49 received a prescription for pharmacotherapy within 6 months before or after surgery. CONCLUSION One quarter of TJA patients meet criteria to receive osteoporosis medications, but only 5% receive therapy preoperatively or postoperatively. This lack of preoperative osteoporosis screening and treatment may contribute to periprosthetic fracture risk.
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Affiliation(s)
- James T Bernatz
- Department of Orthopedics & Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Andrew E Brooks
- Department of Orthopedics & Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Matthew W Squire
- Department of Orthopedics & Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Richard I Illgen
- Department of Orthopedics & Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Neil C Binkley
- Divisions of Endocrinology and Geriatrics, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Paul A Anderson
- Department of Orthopedics & Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Bonnevialle P, Marcheix PS, Nicolau X, Arboucalot M, Lebaron M, Chantelot C, Mainard D, Ehlinger M. Interprosthetic femoral fractures: Morbidity and mortality in a retrospective, multicenter study. Orthop Traumatol Surg Res 2019; 105:579-585. [PMID: 30514624 DOI: 10.1016/j.otsr.2018.07.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 06/26/2018] [Accepted: 07/02/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Interprosthetic femoral fractures (IFF) are becoming more frequent; however they have not been the subject of many publications and the largest study on this topic includes only 30 cases. The complication rate and clinical outcomes have only been evaluated in small case series. This led us to conduct a retrospective, multicenter, observational study in IFF patients with at least 12 months' follow-up to (1) determine the mortality and morbidity (2) determine the clinical and radiological outcomes and (3) identify elements of the treatment indications. HYPOTHESIS The morbidity and mortality rates will be comparable to those in recent studies on this topic. MATERIALS AND METHODS The study included 51 patients (49 women, 2 men) with a mean age of 82.8±9.2 years [55-97], a mean Parker score of 4.9±2.4 and a mean Katz score of 4.4±1.4 who had suffered an IFF between 2009 and 2015. According to the SoFCOT modifications of the Vancouver classification, 30 fractures were interprosthetic in the shaft segment where there were no implants (19 double C and 11 type D (corresponding to a type C with less than two diaphysis widths between the extension stems of the hip and knee implants)) while 21 were periprosthetic, with 12 around the THA (11 B1 and 1 B3) and 9 around the TKA (8 B1 and 1 B3). One patient was treated conservatively with an external fixator but died the next day, 2 patients received a new total hip arthroplasty and 47 underwent plate fixation of their fracture (one patient was treated non-operatively because of poor medical condition). RESULTS One patient was lost to follow-up, and nine died during the first 6 months. Six early surgical site complications occurred and 13 general ones. Within 1 year of the IFF, there were six mechanical complications, two surgical site infections and two cases of loosening. The mean follow-up was 27.6±17.2 months. The mean time to union was 19.25±8.8 weeks. The mean final Parker score was 3.37±2.6 and the mean Katz score was 2.98±1.8; both were significantly lower than the initial scores. Six patients died between months 12 and 50. The overall mortality at the final review was 31% (16/51) with a median survival of 3.45 years. DISCUSSION Our hypothesis was not confirmed because the mortality and morbidity in our study were higher than in other published studies. In the six relevant studies identified, the surgical site infection rate was 12.3%, the major revision rate was 11.6% and the mortality rate was 6.5%. In our study, these values were 24%, 24% and 31%, respectively. These worse results may be explained by the very fragile nature of the studied population and the surgeons not following appropriate technical rules for fracture fixation. LEVEL OF EVIDENCE IV, Retrospective study.
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Affiliation(s)
- Paul Bonnevialle
- Département universitaire d'orthopédie traumatologie, hôpital Pierre-Paul-Riquet, place Baylac, 31052 Toulouse, France.
| | - Pierre-Sylvain Marcheix
- Service de chirurgie orthopédique et de traumatologie, 2, avenue Martin-Luther-King, 87000 Limoges, France
| | - Xavier Nicolau
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France
| | - Marine Arboucalot
- Département universitaire d'orthopédie traumatologie, hôpital Pierre-Paul-Riquet, place Baylac, 31052 Toulouse, France
| | - Marie Lebaron
- Service de chirurgie orthopédique et de traumatologie, hôpital Nord, chemin des Bourrely, 13015 Marseille, France
| | - Christophe Chantelot
- Service de chirurgie orthopédique et de traumatologie, place de Verdun, 59037 Lille, France
| | - Didier Mainard
- Service de chirurgie orthopédique et de traumatologie, hôpital central, CHU de Nancy, 29, avenue de Lattre-de-Tassigny, 54000 Nancy, France
| | - Matthieu Ehlinger
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France
| | -
- Groupe d'étude en traumatologie [French Orthopedic Trauma Society], 56, rue Boissonade, 75014 Paris, France
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Anderson PA, Bernatz JT, Binkley NC, Blank RD. Letter to the Editor on "Choices, Compromises, and Controversies in Total Knee and Total Hip Arthroplasty Modifiable Risk Factors: What You Need to Know". J Arthroplasty 2019; 34:1037-1039. [PMID: 30853159 DOI: 10.1016/j.arth.2019.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/12/2019] [Indexed: 02/01/2023] Open
Affiliation(s)
- Paul A Anderson
- Department of Orthopedics Surgery and Rehabilitation, University of Wisconsin UWMF Centennial Building, Madison, WI
| | - James T Bernatz
- Department of Orthopedics Surgery and Rehabilitation, University of Wisconsin UWMF Centennial Building, Madison, WI
| | - Neil C Binkley
- University of Wisconsin Osteoporosis Clinical Research Program, Madison, WI
| | - Robert D Blank
- Department of Endocrinology, Metabolism, and Clinical Nutrition, Medical College of Wisconsin, Milwaukee, WI
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Prince JM, Bernatz JT, Binkley N, Abdel MP, Anderson PA. Changes in femoral bone mineral density after total knee arthroplasty: a systematic review and meta-analysis. Arch Osteoporos 2019; 14:23. [PMID: 30798359 DOI: 10.1007/s11657-019-0572-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 01/27/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Bone loss after total knee arthroplasty (TKA) may lead to periprosthetic fractures that are associated with significant costs (morbidity, economic, etc.) and pose a challenge to operative fixation. This meta-analysis quantifies the change in bone mineral density (BMD) of the distal femur after primary TKA. METHODS A systematic review of six databases was performed by two independent reviewers. Studies that reported bone density after knee arthroplasty were identified and inclusion/exclusion criteria was applied. Data were extracted and analyzed using the Comprehensive Meta-Analysis Software. RESULTS Fourteen studies were included in the analysis. The average decrease in BMD was 0.09 [0.05, 0.13], 0.14 [0.08, 0.20], 0.16 [0.10, 0.23], and 0.16 [0.12, 0.20] g/cm2 at 3, 6, 12, and 24 months, respectively, corresponding to a 9.3%, 13.2%, 15.8%, and 15.4% BMD loss. A high degree of heterogeneity existed between the studies (I2 > 90% at most time points). CONCLUSION In summary, there is a rapid and significant 15% decrease in BMD in the first 6 months after TKA that is sustained to 24 months. Better understanding regarding how perioperative optimization of bone health may affect BMD loss and the incidence of periprosthetic fracture is essential. LEVEL OF EVIDENCE Therapeutic Level II.
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Affiliation(s)
- Joel M Prince
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, UWMF Centennial Building, 1685 Highland Avenue, 6th Floor, Madison, WI, 53705, USA
| | - James T Bernatz
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, UWMF Centennial Building, 1685 Highland Avenue, 6th Floor, Madison, WI, 53705, USA
| | - Neil Binkley
- University of Wisconsin Osteoporosis Clinical Research Program, Madison, WI, 53705, USA
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 65905-53705, USA
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, UWMF Centennial Building, 1685 Highland Avenue, 6th Floor, Madison, WI, 53705, USA.
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Rhee SJ, Cho JY, Choi YY, Sawaguchi T, Suh JT. Femoral Periprosthetic Fractures after Total Knee Arthroplasty: New Surgically Oriented Classification with a Review of Current Treatments. Knee Surg Relat Res 2018; 30:284-292. [PMID: 29715713 PMCID: PMC6254877 DOI: 10.5792/ksrr.17.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/28/2017] [Accepted: 08/03/2017] [Indexed: 12/19/2022] Open
Abstract
Purpose As the number of total knee arthroplasties (TKAs) increases, the incidence of femoral periprosthetic fractures after TKA is also increasing. This review aimed to suggest a new surgically oriented classification system for femoral periprosthetic fractures. Methods We investigated the classifications, and current treatment trends for femoral periprosthetic fractures after TKA by means of a thorough review of the relevant literature. Results Numerous studies reported good results of surgical treatment with modern fixatives including locking compression plates and retrograde intramedullary nails. However, few classifications of femoral periprosthetic fractures reflect the recent developments in surgical treatment. Conclusions We recommend that surgical management be considered the first-line treatment for femoral periprosthetic fractures after TKA. Our new classification will help in deciding the surgical treatment option for femoral periprosthetic fractures after TKA.
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Affiliation(s)
- Seung Joon Rhee
- Department of Orthopedic Surgery, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jae Young Cho
- Department of Orthopedic Surgery, Haeundae Bumin Hospital, Busan, Korea
| | - Yoon Young Choi
- Department of Diagnostic Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Takeshi Sawaguchi
- Department of Orthopedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, Toyama, Japan
| | - Jeung Tak Suh
- Department of Orthopedic Surgery, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Hernigou P, Auregan JC, Bastard C, Housset V, Flouzat-Lachaniette CH, Dubory A. Higher prevalence of periprosthetic fractures with ceramic on polyethylene hip bearing compared with ceramic on ceramic on the contralateral side: a forty year experience with hip osteonecrosis. INTERNATIONAL ORTHOPAEDICS 2018; 42:1457-1461. [PMID: 29504054 DOI: 10.1007/s00264-018-3863-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 02/21/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE It is unclear whether late THA periprosthetic femoral fractures are related to a mechanical mechanism that decreases strength of the femur (for example, loosening) or to a biological problem as osteolysis. It is also unknown if ceramic on ceramic bearing couples decrease the risk of late periprosthetic fractures as a result of the absence of wear and osteolysis. MATERIAL AND METHODS We therefore asked whether the cumulative long-term fractures were different according to the couple of friction ceramic on ceramic or ceramic on polyethylene in 327 patients (654 hips) with bilateral THA (one ceramic-ceramic, and the contralateral ceramic-polyethylene) who had THA with cemented stems performed between from 1978 to 2000 for osteonecrosis. RESULTS There were two intra-operative fractures (0.3%). The median follow-up was 22 years (range, 15-40 years), and at the most recent follow-up, the cumulative number of late (after 7 years of follow-up) post-operative fractures was 32 (5% of 654 hips). Fractures were unilateral, which means for the 327 patients, a 10% rate of fractures. Periprosthetic fractures increased in number with follow-up: seven fractures (1% of 654 hips) occurred within ten years of THA implantation, 20 (3%) within 20 years, 26 (4%) within 30 years, and 32 (5%) within 40 years. The risk of fracture was influenced (p < 0.001) by the bearing surfaces at the time of prosthetic implantation, low (0.3%) for ceramic on ceramic (1/32 fractures; 1/327 hips), high (10%) for ceramic on PE (31/32 fractures; 31/327 hips). CONCLUSION In summary, when the contralateral hip of the same patient is the control, after 40 years of follow-up, post-operative fractures occur 30 times more often on the side with PE cup than on the side with ceramic/ceramic bearing.
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Lyons RF, Piggott RP, Curtin W, Murphy CG. Periprosthetic hip fractures: A review of the economic burden based on length of stay. J Orthop 2018; 15:118-121. [PMID: 29657453 DOI: 10.1016/j.jor.2018.01.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 01/12/2018] [Indexed: 10/18/2022] Open
Abstract
Introduction With the increasing rates of total hip replacements being performed worldwide, there is an increasing incidence of periprosthetic fractures. As our patients' demographics change to include older patients with multiple medical co-morbidities, there is a concurrent increase in morbidity and mortality rates. This leads to longer hospital stays and increasing hospital costs. In the current economic climate, the cost of treating periprosthetic fractures must be addressed and appropriate resource and funding allocation for future provision of services should be planned. Materials and methods All periprosthetic hip fractures that were admitted to a single trauma unit over a three-year period were reviewed. Independent chart review, haematological and radiological review was undertaken. All patients with a periprosthetic fracture associated with a total hip arthroplasty or hemiarthroplasty were included. Follow up data including complications were collated. Data from the hospital inpatient database and finance department was utilized for cost analysis. All statistical analysis was preformed using Minitab version 17. Results 48 patients were identified who met the inclusion criteria for review. The majority of participants were female with a mean age of 73.5 years. The mean time to fracture was 4.5 years (9 months-18.5 years). Periprosthetic fracture was associated with total hip arthroplasty in 24 cases and a Vancouver B2 classification was most common at n = 20. The majority of patients had revision arthroplasty, with a mean length of stay of 24 days for the whole cohort (9-42). Vancouver B3 fractures had the longest inpatient stay at a mean of 26 days. The mean cost of for a full revision of stem with additional plate and cable fixation was over €27000 compared to €14,600 for ORIF and cable fixation based on length of hospital stay. Conclusion The prolonged length of stay associated with Vancouver B2 and B3 fractures leads to increased costs to the healthcare service. Accurately calculating the costs of total treatment for periprosthetic fractures is difficult due to a lack of transparency around implant and staffing costs. However, as we can expect increasing incidence of periprosthetic fractures presenting in the coming years it is paramount that we make financial provisions within healthcare budgets to ensure we can treat these patients appropriately.
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Affiliation(s)
| | | | - William Curtin
- Galway University Hospital, Saolta Hospital Group, Ireland
| | - Colin G Murphy
- Galway University Hospital, Saolta Hospital Group, Ireland
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Nascimento G, Silva C, Marques R, Silva C, Oliveira JF, Santos J, Leiria J. Periprosthetic pathologic fracture following tibial Echinoccocosis: A case report. Int J Surg Case Rep 2018; 51:231-236. [PMID: 30216900 PMCID: PMC6139003 DOI: 10.1016/j.ijscr.2018.08.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 01/25/2023] Open
Abstract
Cystic Echinococcus in the bone is rare, comprising 0.5%–2.5% of all human hydatidosis. Association of Hydatid disease to pathologic fractures envolving knee prosthesis have not yet been described. A combined surgical and medical approach is of paramount importance to avoid recurrence. Resulting osseus defects is challenging and require specific prosthesis when treating this entity.
Introduction Hydatid disease in humans caused by the parasitic tapeworm Echinococcus granulosus has an osseous involvement of about 0.5%–2.5% of all cases in humans. The location of hydatid cysts in the tibia is seldom described in the medical literature, and its diagnosis and treatment is challenging. Case report This paper presents a patient, with a long term, well tolerated, bilateral total knee arthroplasty (TKA), treated at our clinic, with a recent history of pain and oedema in her left upper leg. After achieving a, radiologically and histhopathologically, well documented, diagnosis of Echinoccocosis lesion in her left proximal tibia, a surgical intervention was planed, a wide resection of the cyst performed, and a specific anti-helmintic therapy was instituted. Four years later, she returns to our observation complaining of pain and unable to bear weight on her left knee, from which a pathologic fracture, adjacent to the tibial component, was diagnosed. After surgical debridement of the newly advanced hydatid cyst growth, the TKA was revised, and due to the tibial component failure and the femoral implant loosening, a semi-constrained total knee revision arthroplasty was executed. Functional outcome was excellent. Conclusion Although challenges in treatment of musculoskeletal hydatid cysts (HC) lesions have been documented, data regarding the musculoskeletal HC lesions resembling tumor is scarce, and those resulting in a prosthetic failure have not been published. The authors intend to add data concerning the therapeutic approach to this entity.
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Affiliation(s)
- Germano Nascimento
- Hospital Dr. Manoel Constâncio, Lg. Eng. Bioucas, 2200-200, Abrantes, Portugal.
| | - Carmen Silva
- Hospital Dr. Manoel Constâncio, Lg. Eng. Bioucas, 2200-200, Abrantes, Portugal.
| | - Raquel Marques
- Hospital Dr. Manoel Constâncio, Lg. Eng. Bioucas, 2200-200, Abrantes, Portugal.
| | - Carlos Silva
- Hospital Dr. Manoel Constâncio, Lg. Eng. Bioucas, 2200-200, Abrantes, Portugal.
| | | | - Jorge Santos
- Hospital Dr. Manoel Constâncio, Lg. Eng. Bioucas, 2200-200, Abrantes, Portugal.
| | - João Leiria
- Hospital Dr. Manoel Constâncio, Lg. Eng. Bioucas, 2200-200, Abrantes, Portugal.
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Freimoser F, Grechenig S, Ofenhitzer A, Bakota B, Staresinic M, Pfeifer CG. Anatomical and radiological evaluation of less invasive stabilisation system (LISS) in correlation with knee lateral collateral ligament insertion. Injury 2017; 48 Suppl 5:S56-S60. [PMID: 29122124 DOI: 10.1016/s0020-1383(17)30741-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The Less Invasive Stabilisation System (LISS) is an angle-stable plate that enables treatment of distal femoral comminuted and periprosthetic fracture. As it is placed through a minimally-invasive lateral approach, lateral knee pain is a commonly described symptom after its application. This study investigates knee lateral collateral ligament (LCL) iatrogenic injury during LISS plate fixation. A cadaver study was performed and a retrospective radiological investigation with the analysis of its clinical application was conducted to evaluate possible knee LCL damage. METHODS The cadaver study included 13 human lower extremities, treated with LISS. After application, lateral knee side was dissected, implants were removed and distances between the drill holes and LCL origin were measured. In the retrospective radiological evaluation, postoperative X-rays for patients treated with distal femoral LISS plate in the University Hospital Regensburg, Germany from January 2010 to December 2015 were examined. Following a protocol described by Pietrini et al., the LCL origin on postoperative X-rays was calculated, both in lateral and anterior-posterior (AP) view, and distances between the plate and its closest locking screw to the LCL origin were measured. RESULTS In the cadaver study, the mean distance between the closest drilling hole and the ligament origin was 14.0mm (range 9-21mm; SD 3.8mm). Twenty-two patients matched the inclusion criteria for the retrospective radiological study. In lateral view, the mean distance between the origin and the closest locking screw was 6.3mm (range 0-16.4mm; SD 4.7mm); the mean distance between the origin and the plate was 3.1mm (range 0-13.9mm; SD 4.1mm). In AP view, the mean distance between LCL origin and the nearest screw was 2.4mm (range 0-7.6mm; SD 2.4mm). The mean distance between the origin and the most distal locking screw was 9.2mm (range 0-17.5mm; SD 4.0mm). DISCUSSION The LISS is a safe option to treat distal femoral fractures in respect to the LCL. Due to close proximity, the LCL might be harmed; therefore, lateral knee pain or lateral instability after implantation should be assessed in further treatment.
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Affiliation(s)
- Florian Freimoser
- Department of Trauma and Orthopaedic Surgery, University Medical Centre Regensburg, Germany
| | - Stephan Grechenig
- Department of Trauma and Orthopaedic Surgery, University Medical Centre Regensburg, Germany
| | - Anna Ofenhitzer
- Department of Trauma and Orthopaedic Surgery, University Medical Centre Regensburg, Germany
| | - Bore Bakota
- Trauma and Orthopaedic Surgery department, Brighton and Sussex University Hospital, NHS Trust, UK
| | - Mario Staresinic
- Trauma and Orthopaedic Clinic, University Hospital Merkur, Zagreb, Croatia
| | - Christian G Pfeifer
- Department of Trauma and Orthopaedic Surgery, University Medical Centre Regensburg, Germany.
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Trousdale WH, Abdel MP, Viste A, Trousdale RT, Callaghan JJ, Berry DJ. Seasonality of Periprosthetic Femur Fractures in 12,700 Primary and Revision Total Hip Arthroplasties. J Arthroplasty 2017; 32:2000-2004. [PMID: 28341277 DOI: 10.1016/j.arth.2017.02.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/14/2017] [Accepted: 02/20/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Periprosthetic femur fractures after primary and revision total hip arthroplasty (THA) are one of the most common long-term reasons for reoperation after THA. Previous investigations have analyzed the incidence and risk factors of these fractures. No previous study, however, has analyzed a variation in periprosthetic femur fractures between meteorologic seasons. The aim of this study was to compare the incidence of periprosthetic femur fractures after primary and revision THAs depending on the meteorologic season. METHODS We identified 8920 patients (10,672 hips) who underwent primary THAs and 1830 patients (1998 hips) who underwent revision THAs at our institution between 1995 and 2011. All patients resided in the Upper Midwest at the time of surgery. Patients who experienced periprosthetic femur fractures were identified and categorized based on the meteorologic season. A Cox model was used to assess the association of seasonality with the risk of fracture. RESULTS During the study period, 165 primary THAs and 80 revision THAs sustained a periprosthetic femur fracture. Using winter as a reference, the risk of a periprosthetic femur fracture after primary THA was not statistically higher in the spring (hazard ratio [HR] = 1.3; P = .2), autumn (HR = 1.4; P = .2), and summer (HR = 1.415; P = .1). Similarly, the risk of periprosthetic femur fracture after revision THA was not statistically higher in the spring (HR = 0.9; P = .6), autumn (HR = 0.6; P = .1), and summer (HR = 0.9; P = 1.0). CONCLUSION The risk of periprosthetic femur fracture after primary and revision THA does not significantly differ between meteorologic seasons.
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Affiliation(s)
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anthony Viste
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - John J Callaghan
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Costi K, Solomon LB, McGee MA, Rickman MS, Howie DW. Advantages in Using Cemented Polished Tapered Stems When Performing Total Hip Arthroplasty in Very Young Patients. J Arthroplasty 2017; 32:1227-1233. [PMID: 28082045 DOI: 10.1016/j.arth.2016.11.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 09/06/2016] [Accepted: 11/15/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The risk of revision following primary total hip arthroplasty (THA) is increased in young patients who undergo THA for pathologies other than primary osteoarthritis. We report the results of primary THA performed with cemented polished stems in patients aged 40 years and younger for pathologies other than primary osteoarthritis. METHODS We investigated 52 patients (65 hips) who underwent primary THA for secondary osteoarthritis with a cemented tapered polished stem between 1990 and 2007. Clinical and radiographic outcomes, available in 46 patients (57 hips), included the Harris Hip Scores, Societe Internationale de Chirurgie Orthopedique et de Traumatologie activity, patient satisfaction, stem survival and reoperations, and assessment of prosthesis-cement-bone radiolucencies, osteolysis, and femoral bone deficiencies. RESULTS Median patient age was 34 years (16-40) and follow-up was 14 years (mean 13, range 5-22). Stem survival to the endpoint revision for loosening was 100% and to the endpoint revision for any reason, excluding infection was 88% (95% confidence interval 78-98) at 16 years. No stem was revised for aseptic loosening. Nine stems were revised for other reasons. Radiographically, one stem was definitely loose at 16 years. The median patient Harris pain score improved from marked pain to no pain at latest follow-up. Patient activity level improved, albeit minimally, for 8 years after surgery. At latest follow-up, 98% of the patients remained satisfied with their surgery. CONCLUSION Primary THA with a cemented polished stem shows excellent results in young patients with pathology other than primary osteoarthritis. In addition, the stem design facilitates cement within cement exchange and therefore preservation of proximal femoral bone stock at revision surgery.
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Affiliation(s)
- Kerry Costi
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Lucian B Solomon
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital and Discipline of Orthopaedics and Trauma, The University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Margaret A McGee
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mark S Rickman
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital and Discipline of Orthopaedics and Trauma, The University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Donald W Howie
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital and Discipline of Orthopaedics and Trauma, The University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Park KJ, Menendez ME, Barnes CL. Perioperative Periprosthetic Fractures Associated With Primary Total Hip Arthroplasty. J Arthroplasty 2017; 32:992-995. [PMID: 27866949 DOI: 10.1016/j.arth.2016.08.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 08/16/2016] [Accepted: 08/22/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Periprosthetic fracture (PPF) is a rare but devastating complication of primary total hip arthroplasty (THA). While PPF is associated with increased morbidity and mortality, early revision rate, and poor patient outcome, there is a paucity of data on patient and hospital-dependent risk factors. Using a large administrative database, we investigated epidemiology and the risk factors associated with perioperative PPF after primary THA. METHODS We performed a retrospective review of the National Inpatient Sample records from 2006 to 2011 and identified 1062 PPFs of 1,187,969 patients using International Classification of Diseases, Ninth Revision code for PPF (996.44). We then analyzed sociodemographic characteristics, comorbidities, and hospital characteristics of our study population. RESULTS The overall incidence of PPF in National Inpatient Sample database was 0.089% (8.9 per 10,000 THAs). Patient-dependent risk factors were: female (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.67-2.22), low household income (OR 1.4, 95% CI 1.18-1.65), Medicaid (OR 1.89, 95% CI 1.39-2.57), and uninsured (OR 2.74, 95% CI 1.63-4.61). Patients with malnutrition and hemiparesis/hemiplegia were associated 10-fold and 6-fold risk of PPF. Nonteaching hospitals (OR 1.15, 95% CI 1.01-1.32), hospitals in northeast (OR 1.29, 95% CI 1.04-1.59), and rural hospitals (OR 1.27, 95% CI 1.06-1.53) had higher incidence of PPF. CONCLUSION Our study demonstrates that the incidence of PPF was low in our study population, and greater awareness is needed when performing primary THAs in patients with risk factors identified in our study to prevent PPF.
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Affiliation(s)
- Kwan J Park
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mariano E Menendez
- Department of Orthopaedic Surgery, Tufts University School of Medicine, Boston, Massachusetts
| | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Kim JT, Jeong HJ, Lee SJ, Kim HJ, Yoo JJ. Adjuvant Teriparatide Therapy for Surgical Treatment of Femoral Fractures; Does It Work? Hip Pelvis 2016; 28:148-156. [PMID: 27777917 PMCID: PMC5067391 DOI: 10.5371/hp.2016.28.3.148] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 07/26/2016] [Accepted: 08/03/2016] [Indexed: 01/17/2023] Open
Abstract
PURPOSE Atypical femoral fracture (AFF), periprosthetic femoral fracture (PPFF) and femoral nonunion (FNU) are recalcitrant challenges for orthopedic surgeons. Teriparatide (TPTD) had been demonstrated to have anabolic effects on bone in various studies. We postulated that adjuvant TPTD after operation would enhance biologic stimulation for bone formation. We investigated (1) whether the adjuvant TPTD could achieve satisfactory union rate of surgically challenging cases such as displaced AFF, PPFF and FNU; (2) whether the adjuvant TPTD could promote development of abundant callus after surgical fixation; (3) whether the adjuvant TPTD had medically serious adverse effects. MATERIALS AND METHODS Thirteen patients who agreed to off label use of TPTD in combination of operation were included in this retrospective case series. Median patients' age was 68.7 years, and there were three male and ten female patients. Their diagnoses were nonunion in six patients and acute fracture in seven. Medical records and radiographic images were reviewed. RESULTS Twelve of thirteen fractures were united both clinically and radiologically within a year after adjuvant TPTD. Union completed radiologically median 5.4 months and clinically 5.7 months after the medication, respectively. Callus appeared abundantly showing median 1.4 of fracture healing response postoperatively. There was no serious adverse reaction of medication other than itching, muscle cramp, or nausea. CONCLUSION Even appropriate surgical treatment is a mainstay of treatment for AFF, PPFF, and FNU, the current report suggested that adjuvant TPTD combined with stable fixation results in satisfactory outcome for the challenging fractures of femur.
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Affiliation(s)
- Jung Taek Kim
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung Jun Jeong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Soong Joon Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Joong Kim
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea.; Seoul National University Medical Research Center, Seoul, Korea
| | - Jeong Joon Yoo
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea
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