In brief: classifications in brief: Vancouver classification of postoperative periprosthetic femur fractures

Applications of Natural Language Processing for Automated Clinical Data Analysis in Orthopaedics

Natural language processing is an exciting and emerging field in health care that can transform the field of orthopaedics. It can aid in the process of automated clinical data analysis, changing the way we extract data for various purposes including research and registry formation, diagnosis, and medical billing. This scoping review will look at the various applications of NLP in orthopaedics. Specific examples of NLP applications include identification of essential data elements from surgical and imaging reports, patient feedback analysis, and use of AI conversational agents for patient engagement. We will demonstrate how NLP has proven itself to be a powerful and valuable tool. Despite these potential advantages, there are drawbacks we must consider. Concerns with data quality, bias, privacy, and accessibility may stand as barriers in the way of widespread implementation of NLP technology. As natural language processing technology continues to develop, it has the potential to revolutionize orthopaedic research and clinical practices and enhance patient outcomes.

A Consecutive Series of Vancouver B2 Periprosthetic Femur Fractures Treated With Contemporary Monoblock Versus Modular Revision Stems: Clinical and Radiographic Outcomes

BACKGROUND

Tapered fluted titanium (TFT) stems are the implant design of choice for managing Vancouver B2 periprosthetic femur fractures (PFFs), producing reliable results over the past few decades. The aim of this study was to compare the radiographic and clinical outcomes of Vancouver B2 PFFs treated with contemporary monoblock versus modular TFTs.

METHODS

A consecutive series of 113 patients (72 women, 64%, mean age 70 years [range, 26 to 96]) who had a B2 PFF were treated with either a monoblock (n = 42) or modular (n = 71) TFT stem between 2008 and 2021. The mean body mass index was 30 ± 7. The mean follow-up was 2.9 years. A radiographic review was performed to assess leg length and offset restoration, endosteal cortical contact length, and stem subsidence. Kaplan-Meier analyses were used to determine survivorship without revision, reoperation, or dislocation.

RESULTS

There was no difference in the restoration of leg length (0.3 ± 8.0 mm) or offset (2.8 ± 8.2 mm) between the monoblock and modular cohorts (P > .05). Mean endosteal cortical contact length (47.2 ± 26.6 versus 46.7 ± 2 6.4 mm, P = .89) and stem subsidence (2.7 ± 3.5 versus 2.4 ± 3.2 mm, P = .66) did not differ. No difference in patient-reported outcome measures (Hip Disability and Osteoarthritis Outcome Score-Joint Replacement; Veterans RAND 12 Item Health Survey Physical and Mental; visual analog score; and Lower Extremity Activity Scale) between the groups was observed. Survivorship at 2 years free from reoperation, revision, and dislocation was 90.4, 90.3, and 97.6%, respectively, for the monoblock cohort; and 84.0, 86.9, and 90.0%, respectively, for the modular cohort.

CONCLUSIONS

No significant differences in radiographic or clinical outcomes were observed between patients treated with monoblock or modular TFTs in this large series of B2 PFFs.

Last generation fluted modular titanium stem in revision hip arthroplasty: a narrative review of mid- and long-term outcomes

Background and Objective

Tapered fluted titanium stems (TFTS), were introduced to overcome proximal femur bone defects. They obtain stable fixation even in catastrophic proximal bone loss. Modular ones have the advantage to adjust length, rotation, off-set independently from the distal module. Short-term publications have been showing favorable outcomes burdened by an unacceptably high rate of stem failure. Still, there is a paucity of mid- and long-term reports. This narrative review aims at analyzing recent literature on modular TFTS with at least 5 years of minimum follow-up to gain a better understanding of implant survival, performance, and complications.

Methods

A search of the PubMed database was performed with selected key terms. Results were screened after the application of strict inclusion and exclusion criteria. Extracted data were subsequently evaluated to obtain an up-to-date overview of the results and complications of TFTS.

Key Content and Findings

Modular TFTS showed a consistent increase in patient reported outcomes that persists at 10 years and above. Femoral fractures were the most common intraoperative complication. Despite modularity, dislocation still occurs at a variable rate (1.2-12%). With revision for any cause as an endpoint, overall survival approaches 83% after 10 years of follow-up. If femoral revision only is evaluated, excellent survival rates (>95%) have been published. Stem subsidence over 5 mm was reported in less than 5% of patients, only 1 requiring femoral revision. The mean incidence of stem mechanical failure was 3.39%, although most breakages occurred in stems eventually retired from the market.

Conclusions

Satisfactory survival rates were observed, with an acceptable rate of complications. Stem mechanical failure, excluding those stems eventually retired from the market, remains a marginal event. Therefore, the use of modular TFTS in revision surgery is safe and effective even in the long term.

Can Selected Use of Cemented and Uncemented Femoral Components in a Broad Population Produce Comparable Results Following Primary Total Hip Arthroplasty for Osteoarthritis?

INTRODUCTION

Registry data have demonstrated lower rates of revision and periprosthetic fracture in select cohorts with cemented femoral fixation at primary total hip arthroplasty (THA). Whether this is true of all component designs is not known. We hypothesized that selected use of ream-and-broach, triple-tapered uncemented stem designs may provide comparable results to cemented stems.

METHODS

From 2000 to 2018, 5,809 primary THAs were performed with either a cemented (1,304) or ream-and-broach triple-tapered uncemented stem (4,505). Implant choice was at surgeon discretion. The cemented group was older, more often women, and had slightly lower body mass index. A subgroup analysis was performed on patients ≥75-years of age. Statistical weighting accounted for baseline cohort differences.

RESULTS

At 10 years, there was a trend toward higher all-cause revision (Hazards ratio (HR) 1.6, P=0.053) and higher all-cause reoperation (HR 1.6, P=0.02) in the cemented fixation cohort. The cemented fixation group had fewer intraoperative periprosthetic fractures (HR 0.21, P<0.001), but no difference in postoperative fractures (HR 0.99, P=0.96). The same was true in patients ≥75-years. In the ≥75-years subgroup, there was no difference in revision or reoperation at 10 years.

CONCLUSION

Compared to cemented stems, the use of ream-and-broach triple-tapered uncemented stems in select patients, including those ≥75-years, was associated with more intraoperative fractures, but no difference in 10-year implant survivorship. These findings are different than some registry data and suggest that specific uncemented components, implanted in selected patients by experienced surgeons, can perform as well as cemented implants in a broad patient population.

Treatment of periprosthetic femoral fractures following total hip arthroplasty: results of an online survey of the European Hip Society

BACKGROUND

Periprosthetic femoral fractures (PPF) are a devastating complication after total hip arthroplasty (THA). Both trauma and adult reconstruction surgeons or combined teams treat these fractures following management algorithms. The aim of this study is to investigate the current treatment of PPF by members of the European Hip Society (EHS).

METHODS

An online survey of the members of the European Hip Society (EHS) was conducted. 20 cases of periprosthetic fracture were presented and surgeons were asked to answer questions regarding classification, treatment and postoperative treatment protocol.

RESULTS

A total of 132 (130 male; 2 female) EHS members responded. Mean years in surgical practice was 18.8 (min. 1 year; max. 50 years). The preferred surgical method was combined open reduction and internal fixation (ORIF) (30.3%) for AG fractures, ORIF with cables (30.4%) for AL fractures, combined ORIF (cable and plate) for B1 fractures (49.2%), stem revision with cables for B2 fractures (73.1%), stem revision with cables for B3 (55.9%) fractures and combined ORIF (cable and plate: 55.5%) for C fractures. Surprisingly, 10.8% suggested various stem revision techniques for B1 and 17.4% for C fractures. Strong variations were observed regarding postoperative weight-bearing protocol.

CONCLUSIONS

A strong consensus was found for the choice of conservative or surgical treatment of the different PPF types according to the Vancouver Classification. Various stem revision techniques were the preferred surgical techniques for Vancouver B2 (91.2%) and B3 (88.6%) fractures. However, for postoperative weight-bearing, when the ORIF technique was used, a significant variation of protocols was found.

Comparative study of Vancouver type B2 periprosthetic fractures treated by internal fixation versus stem revision

PURPOSE

Currently, accepted treatment for periprosthetic femoral fractures with loose femoral stem indicates its revision; however, recent studies have proposed treating Vancouver type B2 fractures via internal fixation without stem revision, particularly in the elderly or multi-morbid patients. Despite indications for stem revision, some surgeons tend to perform internal fixation. The main goal of this study was therefore to identify the parameters that were significantly different comparing internal fixation to stem revision for Vancouver type B2 fractures.

METHODS

Eighty-one Vancouver B2 periprosthetic femoral fractures, treated between 2010 and 2019, were analysed. The internal fixation (ORIF) and the revision groups were compared. Patients' age, BMI, American Society of Anaesthesiologists (ASA) score, anaesthesia type, operating time, blood loss, surgeons' experience, post-operative weight-bearing, length of hospital stay, and radiological outcome using AGORA roentgenographic assessment were analysed.

RESULTS

Patients chosen for ORIF were significantly older than those treated by stem revision (85.4 vs 75.1 years; p = 0.002). Blood loss was 390.7 and 1141.6 ml in the ORIF and revision groups, respectively (p < 0.0001). The surgical times were 134.5 and 225 min in the ORIF and revision groups, respectively (p < 0.0001). Our analysis of BMI, ASA score, anaesthesia type, length of hospital stay, surgeons' experience and radiological outcome, were not significantly different between the two groups.

CONCLUSION

Revision did not exhibit better radiological results; moreover, internal fixation resulted in significantly less perioperative blood loss and a shorter operating time, concluding that ORIF is a viable alternative to revision arthroplasty, particularly in older patients.

Periprosthetic humerus fractures after shoulder arthroplasty: an evaluation of available classification systems

BACKGROUND

Periprosthetic proximal humerus fractures (PPHFs) are a detrimental complication of shoulder arthroplasty, yet their characterization and management have been poorly studied. We aimed to determine the intra- and interobserver reliability of 4 previously described PPHF classification systems to evaluate which classifications are the most consistent.

METHODS

We retrospectively reviewed 32 patients (34 fractures) that were diagnosed with a PPHF between 1990 and 2017. Patient electronic medical records and research electronic data capture (REDCap) were used for data collection. Post-PPHF radiographs in multiple views for all 34 cases were organized into an encrypted, randomized Qualtrics survey. Four blinded fellowship-trained shoulder and elbow surgeons graded each fracture using previously reported classification systems by (1) Wright and Cofield (1995), (2) Campbell et al (1998), (3) Worland et al (1999), and (4) Groh et al (2008), along with selecting a preferred management strategy for each fracture. Grading was performed twice with at least 2 weeks between each randomized attempt. Intraobserver reliability was calculated as an unweighted Cohen kappa coefficient between attempt 1 and attempt 2 for each surgeon. Interobserver reliability and agreeability between surgeons' preferred management strategies were calculated for each classification system using Fleiss kappa coefficient. The kappa coefficients were interpreted using the Landis and Koch criteria.

RESULTS

The average intraobserver kappa coefficient for each classification was as follows: Wright and Cofield = 0.703, Campbell = 0.527, Worland = 0.637, Groh = 0.699. The overall Fleiss kappa coefficient for interobserver reliability for each classification was as follows: Wright and Cofield = 0.583, Campbell = 0.488, Worland = 0.496, Groh = 0.483. Interobserver reliability was significantly greater with the Wright and Cofield classification. Using Landis and Koch criteria, all the classification systems assessed demonstrated only moderate interobserver agreement. Additionally, the mean interobserver agreeability kappa coefficient for preferred management strategy was 0.490, indicating only moderate interobserver agreement.

CONCLUSION

There is only moderate interobserver reliability among the 4 PPHF classification systems and the preferred management strategy for the fractures assessed. Of the 4 PPHF classification systems, Wright and Cofield demonstrated the greatest mean intraobserver reliability and overall interobserver reliability. Our study highlights a need for the development of a PPHF classification system that can achieve high intra- and interobserver reliability and that can allow for a standardized treatment algorithm in the management of PPHFs.

AAHKS Best Podium Presentation Research Award: Femoral Perforation During Direct Anterior Approach Total Hip Arthroplasty: Incidence, Cohort Characteristics, and Management

BACKGROUND

Cortical perforation during femoral preparation is a recognized complication of total hip arthroplasty (THA) but the incidence, patient characteristics, management, and outcome have not been described for the direct anterior approach (DAA).

METHODS

A database query of all primary and conversion DAA THAs performed by a single surgeon from 2009 to 2021 was used to identify hips that sustained a recognized intraoperative femoral perforation. Radiographs were used to assess stem subsidence, Dorr femur type, and Canal Flare Index.

RESULTS

Among 3,973 THAs, 16 patients (0.4%) sustained perforations during broaching including 8 males and 8 females with a mean age at surgery of 65.6 (range 41-81) years and a mean body mass index of 31.0 (range 19.0-44.4). Two hips were converted to longer primary cementless stems to bypass the perforation. For the remaining 14, the broach was redirected and the same primary stem was implanted. Limited weight-bearing (6 patients) or protected weight-bearing as tolerated with a walker/cane (10 patients) was advised postoperatively. At a mean follow-up of 18.7 (range 4-105) months, all stems were stable with no fractures, subsidence, or revisions. Factors associated with perforation included difficulty with exposure (body mass index >40 or a contracture), measurable osteoporosis (Canal Flare Index <3.0), and abnormal proximal femoral anatomy due to prior trauma, retained hardware, or Perthes disease.

CONCLUSION

In this case series, isolated perforation of an otherwise intact femur during DAA was successfully managed with redirection of the broach, implantation of a primary stem that achieved axial/rotational stability, and protected weight-bearing.

LEVEL OF EVIDENCE

IV, Case Series.

A Role for Modern Primary Cementless Femoral Stems in Revision Hip Arthroplasty

BACKGROUND

In revision total hip arthroplasty (THA) cases with preserved femoral metaphyseal bone, tapered proximally porous-coated "primary" femoral stems may be an option. The objective of this study was to compare outcomes of patients with Paprosky I or II femoral bone loss undergoing revision THA with either a primary metaphyseal-engaging cementless stem or a revision diaphyseal-engaging stem.

METHODS

This was a retrospective analysis of 70 patients with Paprosky I or II femoral bone loss who underwent femoral revision. 35 patients who were revised using a primary cementless femoral stem were compared with 35 patients who underwent femoral revision using a revision diaphyseal-engaging stem. The groups were similar regarding age, gender, body mass index, and American Society of Anesthesiologists. Clinical and radiographic outcomes and complications were compared over an average follow-up of 2.9 years (SD 1.4).

RESULTS

Revision THA was most commonly performed for periprosthetic joint infection (N = 27, 38.6%). The groups were similar with regards to Paprosky femoral classification (P = .56), length of stay (P = .68), discharge disposition (P = .461), operative time (P = .20), and complications (P = .164). There were no significant differences between primary and revision femoral stem subsidence (0.12 vs. 0.75 mm, P = .18), leg length discrepancy (2.3 vs. 4.05 mm, P = .37), and Hip Disability and Osteoarthritis Outcome Score Jr (73.1 [SD 21.1] vs. 62.8 [SD 21.7], P = .088). No patient underwent additional revision surgery involving the femoral component.

CONCLUSION

Use of modern primary cementless femoral stems is a viable option for revision hip arthroplasty in the setting of preserved proximal femoral metaphyseal bone. Outcomes are not inferior to those of revision stems and offer potential benefits.

Treatment of Vancouver B1 periprosthetic femoral fractures using Intrauma Iron Lady® locking plate: A retrospective study on 32 patients

INTRODUCTION

Periprosthetic femoral fractures (PFF) actually represent a serious public health problem. They are reported to occur in 0,1-4.5% of all patients undergoing total hip replacement (THR). PFF are commonly distinguished using the Vancouver classification. This study principal aim is to evaluate results obtained using the Intrauma Iron Lady® Conical Coupling locking plate for the treatment of Vancouver type B1 periprosthetic femoral fractures.

MATERIALS AND METHODS

We enrolled 32 patients affected by Vancouver B1 PFF and treated with the same device. Metal cerclages were additionally used in 12 (38%) patients. A clinical and radiographical post-operative follow-up was then planned at 1, 3 and 6 months after surgery; than the follow-up was annually fixed.

RESULTS

Mean age at the moment of trauma was 76,7 years. All involved femoral stem were uncemented and the they were all radiographically and intraoperativelly judged to be stable. Mean post-operative follow-up period was 5,8 years. 29 patients (91%) presented healed fracture at 6 months follow-up. 9% patients developed a superficial surgical site infection.

DISCUSSION AND CONCLUSIONS

Literature highlights that Vancouver B1 PFF should be treated with open reduction and internal fixation (ORIF) using polyaxial locking plates. However, no single technique has gained universal acceptance to be superior that the other. The current reported healing rate ranges from 40 to 100%. Using the Intrauma Iron Lady® Conical Coupling locking plate, we obtained a healing rate of 91%; this data is consistent with recent literature. Moreover, the role of cerclages in addition to femoral plating is actually controversial because they potentially damage the soft callus vascularization. Our results showed no difference in term of healing rate between patients with and without cerclages, according with some of most recent articles. A prospective study with a higher number of patients should be carried out in order to better evaluate the role of cerclages on healing rate but also the complications frequency after PFF surgical treatment.

Comparison of different fixation techniques for periprosthetic fractures: a biomechanical study of a new implant

INTRODUCTION

The ideal treatment method for periprosthetic fractures is controversial due to the risks of current methods. Single-cortex screw fixation in prosthesis may lead to implant failure. Therefore, we aimed to develop an implant that lowers the risk for complications. For this study, we designed and tested two new implant models. The first model was a plate with a combination of U nails and cerclage holes. The second model was a U nail plate with a screw, which combines a plate screw with U nail (staples). Our study aimed to compare the stability of two newly designed implants with classical treatment modalities. We used 27 (in 3 groups) artificial bone models and 9 different test models.

METHODS

The ISO 7206-4:2010 (E) standards were used for 27 bones in nine groups tested under laboratory conditions. In our study, we examined nine different groups. In group 1, hip the prosthesis was extracted, and a revision femoral stem was embedded. In group 2, periprosthetic fractures were repaired with a plate and cable. In group 3, periprosthetic fractures were repaired with a plate and stapler. In group 4, periprosthetic fractures were repaired with a plate and stapler cable. In group 5, periprosthetic fractures were repaired with a plate stapler and screw. Groups 6 and 7 were the control groups. Group 6 was the only artificial bone group, and group 7 was the prosthesis embedded bone group. Group 8 was periprosthetic fractures treated with unicortical screw fixation with cerclage, and group 9 was periprosthetic fractures treated with unicortical screw fixation. Axial loading was applied to the bones. The yield strength of the system was determined by loading the synthetic bone models with a constant compression speed of 5 mm/min through the centre of motion using the Geratech SH 2000 testing system. During the tests, load and displacement values were recorded, and the stiffness of the models was calculated based on those values.

RESULTS

According to our results, the greatest durability was found in the revision hip prosthesis group (1511 N), and the weakest performance was found in the plate with the stapler implant group (163N). When comparing the data of groups according to compression, significant differences were found in group 2 with groups 1, 4, 5, and 7; group 3 with group 1; group 8 with groups 1 and 5; and group 9 with 1, 5, 7, and according to breakage, significant differences were found in group2 with groups 1, 3, 5, and 7; group 3 with group 1; group 8 with groups 1 and 5; and group 9 with groups 1, 5, and 7 (p<0.001).

DISCUSSION

The revision hip prosthesis treatment for periprosthetic fractures showed the best performance, followed by the plate with stapler screw. In older patients, U nail-augmented implants may be a good alternative for periprosthetic fractures. Unicortical screw and cerclage wire combination fixation results were unsatisfactory results in this study.

CONCLUSION

This is an experimental study, so further studies, especially patient-specific studies, should be made to expand the findings of this study.

Conical Primary Cementless Stem in Revision Hip Arthroplasty: 94 Consecutive Implantations at a Mean Follow-Up of 12.7 years

BACKGROUND

Revision of a failed total hip arthroplasty (THA) poses technical challenges. The use of primary stems for revision can be advantageous for maintaining bone stock and reducing complications: small case series have reported promising results in the short-term to mid-term follow-up. The aim of this study was to evaluate the long-term clinical and functional results and survivorship of a consecutive series of THA femoral component revisions using a conical primary cementless stem (PCS).

METHODS

Ninety-four stem revisions with a preoperative Paprosky I or II defect were analyzed at an average follow-up of 12.7 ± 5.4 years. Aseptic loosening was the reason for revision in 92.5% of cases. Twenty patients were lost to follow-up. Two subgroups were created: Group 1 (n = 59) underwent isolated stem revision; Group 2 (n = 15) underwent complete THA revision. All were evaluated preoperatively and postoperatively based on the Harris Hip Score (HHS), the Western Ontario and McMaster Universities Index (WOMAC) score, and the visual analog scale for pain (VAS). Residual trochanteric pain and length discrepancies were recorded. Radiographic evaluation included signs of osteolysis, subsidence, loosening, and heterotopic ossification.

RESULTS

PCS survivorship was 100% at 5 years and 95.9% at 10 years. Overall, significant postoperative improvements (P < .01) were observed on the HHS (44.3 vs 86.9), WOMAC (42.8 vs 82.8), and VAS (7.0 vs 3.0). Postoperative scores on all scales were higher for Group 1 (P < .01). Three patients (4.1%) underwent further stem revision. Demarcation lines (1 mm) were found in 12 (16.2%) patients and significant heterotopic ossifications in 22 (29.7%).

CONCLUSION

The use of PCS for stem revision in failed THA with a limited femoral bone defect is a reliable option for both isolated stem revision and concomitant cup revision in well-selected patients.

Promising results of revision total hip arthroplasty using a hexagonal, modular, tapered stem in cases of aseptic loosening

Background

Modular stems are widely used in revision total hip arthroplasty (THA) with aseptic loosening being a common reason for revision. Despite the good results reported on the use of modular stem designs, there are only few studies focusing on aseptic revisions and few studies on a hexagonal stem design. The goal of this study is to determine stem survival, clinical and functional outcome along with possible risk factors for implant failure in aseptic revision THA.

Methods

We retrospectively identified 53 patients with aseptic THA revision using a modular hexagonal stem with a minimum follow-up of two years. Femoral bone loss, radiographic and clinical outcomes as well as function measured using the Harris Hip Score (HHS) was assessed. Patients’ previous medical history was analyzed for comorbidities and the body mass index. Stem survival was calculated using the Kaplan-Meier method. Possible risk factors for implant failure were analyzed using the log-rank test. The median age at revision was 69 (IQR 62–73) with a median follow up of 74 months.

Results

Implant survival rates amounted to 90.4% at 3 and 5 years. The median HHS improved by 47 points (34 (IQR 22–47) vs 81 (IQR 59–90) p<0.001). There was a reduced implant survival after 5 years when the revision stem was used following a previous cemented stem (83.4% vs 100%, p = 0.04).

Conclusion

A modular, hexagonal stem can be successfully used in aseptic revision THA with remarkable functional results and excellent survivorship. Revision of a cemented stem using this implant might result in reduced survival which must be considered when planning treatment.

Periprosthetic proximal femoral fractures in cemented and uncemented stems according to Vancouver classification: observation of a new fracture pattern

BACKGROUND

Periprosthetic fractures are increasingly encountered in hip arthroplasty. The Vancouver classification system is widely used. Little knowledge exists regarding the association of the Vancouver classification with either cemented or uncemented stems. The aim was to analyse a series of fractures and determine associations.

METHODS

A series of consecutive patients over 8 years was identified including only post-operative fractures of primary hip arthroplasties. Baseline and radiographic characteristics were recorded including the type of stem fixation (cemented or uncemented) and Vancouver classification. Statistical analysis was performed to determine the association of the Vancouver classification between cemented and uncemented stems.

RESULTS

A total of 172 patients were identified (84 cemented stems, 88 uncemented stems). There were 30 Vancouver A fractures (12 cemented vs.18 uncemented, p > 0.05), 125 Vancouver B fractures (63 cemented vs. 62 uncemented, p > 0.05) and 17 Vancouver C fractures (9 cemented vs. 8 uncemented, p > 0.05). The Vancouver B2 fracture occurred most frequently (N = 95; 44 cemented vs. 51 uncemented, p > 0.05) and consists of four distinct fracture patterns: the previously described comminuted 'burst', clamshell and spiral patterns and the newly observed 'reverse' clamshell. The burst and spiral fracture patterns are significantly associated with cemented stems, and the clamshell pattern is significantly associated with uncemented stems.

CONCLUSIONS

Vancouver A, B and C fractures occur equally in cemented and uncemented stems. Awareness of four distinct Vancouver B2 fracture patterns, including the newly observed reverse clamshell, will aid surgeons in predicting stem instability.

Risk Factors for Periprosthetic Femur Fracture and Influence of Femoral Fixation Using the Mini-Anterolateral Approach in Primary Total Hip Arthroplasty

BACKGROUND

The mini-anterolateral (AL) approach for total hip arthroplasty (THA) has gained popularity. In contrast to other approaches, risk factors for periprosthetic femur fractures have not been well established for the AL approach.

METHODS

Six hundred eighty-four primary THAs performed using the AL approach were retrospectively reviewed for risk factors associated with perioperative periprosthetic femur fractures within 3 months of surgery. Risk factors evaluated were gender, age, body mass index, laterality, and Dorr ratio of the proximal femur. Cemented stems and collared uncemented stems were compared to uncemented tapered-wedge and meta-diaphyseal stems. A Student's t-test was used for continuous variables, and a chi-squared test was used for categorical variables.

RESULTS

Of 684 primary THAs performed, 57 (8.3%) resulted in fracture. Twenty-eight (4.1%) occurred intraoperatively and 29 (4.2%) occurred postoperatively within 90 days. All intraoperative fractures were fixed at the time of surgery and healed uneventfully. Of the postoperative fractures, 15 (2.2%) were amenable to nonoperative management and healed. Fourteen (2.0%) required revision arthroplasty. There was a significantly lower rate of fracture in patients receiving cemented or collared stems (0%, n = 101) than in those receiving tapered-wedge or meta-diaphyseal fitting stems (9.8%, n = 583; P = .0009). Odds of fracture increased with female gender (P = .0063) and increasing Dorr ratio (P = .0003). Analysis showed a trend toward increased risk with older age, but did not achieve statistical significance. Body mass index and laterality showed no statistically significant effect.

CONCLUSION

Performing primary THA via the AL approach, 2.0% of patients had a postoperative fracture requiring revision within the first 3 months. With cemented and collared stems, the fracture rate was significantly lower. Surgeons should consider using cemented or collared stems in high-risk patients.

Biomechanics of Osteoporotic Fracture Fixation

PURPOSE OF REVIEW

Fractures of osteoporotic bone in elderly individuals need special attention. This manuscript reviews the current strategies to provide sufficient fracture fixation stability with a particular focus on fractures that frequently occur in elderly individuals with osteoporosis and require full load-bearing capacity, i.e., pelvis, hip, ankle, and peri-implant fractures.

RECENT FINDINGS

Elderly individuals benefit immensely from immediate mobilization after fracture and thus require stable fracture fixation that allows immediate post-operative weight-bearing. However, osteoporotic bone has decreased holding capacity for metallic implants and is thus associated with a considerable fracture fixation failure rate both short term and long term. Modern implant technologies with dedicated modifications provide sufficient mechanical stability to allow immediate weight-bearing for elderly individuals. Depending on fracture location and fracture severity, various options are available to reinforce or augment standard fracture fixation systems. Correct application of the basic principles of fracture fixation and the use of modern implant technologies enables mechanically stable fracture fixation that allows early weight-bearing and results in timely fracture healing even in patients with osteoporosis.

Re-fractures after periprosthetic femoral fracture: A difficult to treat growing evidence

INTRODUCTION

Periprosthetic fractures are increasing. The treatment is mostly surgical, but it has a high complication rate. Re-fracture and non-union with implant failure are the more frequent complications. Those complications are difficult to treat and can lead to severe disability. The purpose of this study is to determine the clinical results of periprosthetic femoral re-fracture treatment.

MATERIALS AND METHODS

Twenty patients were treated for femoral re-fractures (17 women, 3 men). The mean age and follow-up are 75.7 years (46-95) and 6.15 years (0.4-15) respectively. The diagnosis of new periprosthetic fracture according to Vancouver classification were: 3 type A, 5 type B1, 1 type B2, 2 B3, 8 type C; 1 Lewis-Rorabeck type II. Patients were followed-up clinically, with a Harris Hip Score, and radiologically at 2, 4, 6, 12 months, and then annually.

RESULTS

All patients healed except for two cases in which an infection occurred. Two cases, treated with plate osteosynthesis, had a malunion in varus. Six patients died for unrelated reasons after fracture healing. One patient was excluded because of a follow-up shorter than 12 months. In 16 cases (84%) a Trendelenburg gait or the use of aids for walking has been necessary. At final follow-up the mean HHS was 65 (range 45-82). Fractures treatment differed depending on the type of the fracture, prosthesis stability and bone loss. Tension band wiring, long plate fixation, revision with a long stem with cables or a sandwich technique (two plates or one plate plus one strut graft) have been performed according to fracture type.

CONCLUSIONS

Re-fractures and non-union with implant failure are common after periprosthetic fracture treatment. Infection and malunion are the main complications of their treatment. Residual limping with the necessity of aids even after fracture healing is often present. The choice of a correct surgical strategy is essential to minimize the risk of new complications and ensure the highest possibility to heal. The most important factor is to achieve a good stability, a reasonable vital environment and don't leave new areas of lower resistance uncovered. Poor functional outcome has to be expected especially in refracture after a revision surgery.

The value of a standardized and reproducible surgical technique in treatment of Vancouver B2 periprosthetic fractures: our experience

PURPOSE

To retrospectively review results and complications of our standardized surgical technique addressed exclusively to Vancouver B2 fractures.

METHODS

From January 2006 to July 2016, we treated 235 consecutive patients, 47 males and 188 females, mean age at surgery of 71 ± 10 years, with periprosthetic B2 fractures. Exclusion criteria were other kind of periprosthetic fractures and other femoral fractures. The patients were assessed clinically and radiographically following our standard protocol at the last available follow-up. The mean follow-up time was 6.4 years. Radiographic evaluation was performed according to Beals and Tower's criteria and clinical evaluation was performed using the Harris Hip Score and clinical exam.

RESULTS

From the starter cohort of 235, 207 patients (88.1%) were fully evaluated, while 28 were lost to follow-up. According to Beal and Tower's criteria, we found excellent results in 72 patients (34.8%), good results in 133 patients (64.3%), and poor results in 2 patients (0.9%). Mean HHS was 75 ± 9 points, with a statistically significant correlation between good functional results and better radiographic assessment (p = 0.001). The use of support plate (p = 0.008) and the acetabular revision (p = 0.002) showed a statistically significant distribution with worse radiographic results. Late complications detected were ten dislocations.

CONCLUSION

Our experience suggests that using a standardized and reproducible surgical technique, as our technique proposed, can surely reduce surgical time, the complication rate, and the mortality rate. During acetabular evaluation, the choice of performing a cup revision must be weighed on overall patient's assessment.

Total Hip Arthroplasty by the Direct Anterior Approach Using a Neck-preserving Stem: Safety, efficacy and learning curve

BACKGROUND

The concept of femoral neck preservation in total hip replacement (THR) was introduced in 1993. It is postulated that retaining cortical bone of the femoral neck offers triplanar stability, uniform stress distribution, and accommodates physiological anteversion. However, data on safety, efficacy and learning curve are lacking.

MATERIALS AND METHODS

We prospectively assessed all patients who were operated for a THR with a short neck preserving stem (MiniHip) between 2012 and 2014. The safety and learning curve were assessed by recording operative time; stem size; and adverse events including periprosthetic fracture; paresthesia; and limb length discrepancy (LLD). The cohort was divided into equal groups to assess the learning curve effect, and the cumulative sums (CUSUM) test was performed to monitor intraoperative neck fractures. For assessment of efficacy, Oxford Hip Score (OHS) and Short Form-36 (SF-36) scores were compared preoperatively and postoperatively.

RESULTS

138 patients with median age 62 years (range 35-82 years) were included with a median followup of 42 months (range 30-56 months). The minimum followup was 2.5 years. The OHS, SF-36 (physical and mental component) scores improved by a mean score of 26, 28, and 27 points, respectively. All patients had LLD of <10 mm (1.9 mm ± 1.3). Adverse events included intraoperative neck fracture (n = 6), subsidence (n = 1), periprosthetic fracture (n = 1), paresthesia (n = 12), and trochanteric bursitis (n = 2). After early modification of the technique to use a smaller finishing broach, the CUSUM test demonstrated acceptable intraoperative neck fracture risk. The second surgery group had a reduced risk of intraoperative neck fracture (5/69 vs. 1/69 P = 0.2), reduced operative time (66 vs. 61 min, P = 0.06), and increased stem size (5 vs. 6, P = 0.09) although these differences were not statistically significant.

CONCLUSIONS

The MiniHip stem is safe alternative to standard THR with good functional outcomes but with a learning curve for the surgical technique, implants sizing, and the risk of intraoperative neck fractures.

Radiographic outcomes of cable-plate versus cable-grip fixation in periprosthetic fractures of the proximal femur

BACKGROUND

Newer generation cable-plate designs are commonly used for periprosthetic proximal femur fractures; however, comparisons relative to cable-grips remain limited. The aim of this study was to compare radiographic healing rates of cable-plate versus cable-grip fixation for periprosthetic proximal femur fractures.

PATIENTS AND METHODS

Consecutive patients with an acute or chronic Vancouver A, B1, or B2 periprosthetic proximal femur fracture undergoing trochanteric fixation with a cable-plate (n = 46 cases) or cable-grip (n = 24 cases) system were identified retrospectively from a single-centre hospital database (mean follow-up 28 months [range 6-89 months]). Demographics, radiographic fracture healing, and complications were compared between the 2 groups. Radiographic union rates were not different between the cable-grip versus cable-plate group (67% vs. 76% respectively; p = 0.4). Healing rates of greater trochanteric fractures alone were not different between the cable-plate versus cable-grip groups (75% vs. 71% respectively; p = 0.38). The cable-plates were used for a more diverse range of fracture patterns relative to the cable-grips.

RESULTS

An increased number of cables was associated with radiographic healing (odds ratio 14 [95% confidence interval 2-64]; p = 0.01), and body mass index had a negative correlation with radiographic healing (odds ratio -0.4 [95% confidence interval 0.5-0.9].

CONCLUSIONS

Similar rates of periprosthetic fracture healing were seen using a cable-grip versus cable-plate system; however, the cable-plate system could be used for a more diverse range of fracture patterns.

Survivorship After Periprosthetic Femur Fracture: Factors Affecting Outcome

BACKGROUND

Data addressing risk factors predictive of mortality and reoperation after periprosthetic femur fractures (PPFxs) are lacking. This study examined survivorship and risk ratios for mortality and reoperation after surgical treatment for PPFx and associated clinical risk factors.

METHODS

A retrospective review was performed for 291 patients treated surgically for PPFx between 2004 and 2013. Primary outcomes were death and reoperation.

RESULTS

Mortality at 1 year was 13%, whereas the rate of reoperation was 12%. Greater span of fixation and revision arthroplasty (vs open reduction internal fixation) trended toward a lower likelihood of reoperation.

CONCLUSION

After PPFx, patients have a 24% risk of either death or reoperation at 1 year. Factors contributing to increased mortality are nonmodifiable. Risk of reoperation is minimized with greater span of fixation and performance of revision arthroplasty.

Imaging of the Painful Hip Arthroplasty

The incidence of complications following total hip arthroplasty is low, but due to the frequency of the procedure, they are quite commonly encountered and require appropriate investigation. Complications include aseptic loosening, infection, foreign body granulomatosis (osteolysis), adverse reactions to metal debris, periprosthetic fracture, heterotopic ossification, hardware failure, and a range of soft tissue complications, all of which may result in pain. Relevant imaging findings are illustrated and the role of various imaging modalities is reviewed. A suggested approach for the radiological investigation of each potential complication is outlined, based on our experience at a specialist referral unit.

Causes of failure in periprosthetic fractures of the hip at 1- to 14-year follow-up

INTRODUCTION

The results and causes of failure for 61 patients undergoing surgery for femoral hip periprosthetic fracture are reported.

MATERIALS AND METHODS

Fractures were classified according to the Vancouver System. Osteosynthesis was performed in 88% of cases and prosthetic revision in 12% of cases. Clinical and functional outcomes were assessed according to the Harris Hip Score and radiological results were evaluated using Beals and Tower's criteria.

RESULTS

At a mean follow-up of 32 months, the Harris Hip Score was 73.1 and the radiological results were excellent-to-good in 72.2% of patients after the first surgery. At the end of treatment, complete healing of the fracture and stability of the prosthesis was found in 87.3% of patients. The most relevant result was the recovery of walking in 73.8% of patients. Mortality after surgery was 1.6% at 3 months and 3.3% at 12 months. A higher mortality rate occurred when surgery was delayed more than 5 days after trauma.

CONCLUSIONS

The analysis of our cases shows that in Vancouver type B1 fractures treated with plating osteosynthesis, there were worse outcomes in total hip arthroplasty with cemented stems compared with uncemented stems. In Vancouver type B2 fractures with cementless straight stems, osteosynthesis with a plate can be a valid option. In Vancouver type C fractures, the stability of the stem must be carefully assessed.

Outcomes and complications of total hip replacement in super-obese patients

The purpose of this study was to examine the complications and outcomes of total hip replacement (THR) in super-obese patients (body mass index (BMI) > 50 kg/m2) compared with class I obese (BMI 30 to 34.9 kg/m2) and normal-weight patients (BMI 18.5 to 24.9 kg/m2), as defined by the World Health Organization.

A total of 39 THRs were performed in 30 super-obese patients with a mean age of 53 years (31 to 72), who were followed for a mean of 4.2 years (2.0 to 11.7). This group was matched with two cohorts of normal-weight and class I obese patients, each comprising 39 THRs in 39 patients. Statistical analysis was performed to determine differences among these groups with respect to complications and satisfaction based on the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, the Harris hip score (HHS) and the Short-Form (SF)-12 questionnaire.

Super-obese patients experienced significantly longer hospital stays and higher rates of major complications and readmissions than normal-weight and class I obese patients. Although super-obese patients demonstrated reduced pre-operative and post-operative satisfaction scores, there was no significant difference in improvement, or change in the score, with respect to HHS or the WOMAC osteoarthritis index.

Super-obese patients obtain similar satisfaction outcomes as class I obese and normal-weight patients with respect to improvement in their scores. However, they experience a significant increase in length of hospital stay and major complication and readmission rates.

Cite this article: Bone Joint J 2013;95-B:758–63.

Functional outcome and mortality in geriatric distal femoral fractures

BACKGROUND

Fragility fractures are a major health care problem worldwide. Due to the ageing population an increase of distal femoral fractures is to be expected. We studied the long-term functional outcome and their influencing factors in geriatric patients with LISS-plated distal femoral fractures.

PATIENTS AND METHODS

A cohort study with functional long-term follow up examination was carried out in a level one trauma centre on distal femoral fracture patients 65 years and older. Of 53 consecutive patients who were treated in our hospital, 43 patients with a mean age of 80 years met our inclusion criteria. 48.8% died within the study period of 5.3 years. On the remaining patients the residential status, the Barthel index and the Parker score were assessed.

RESULTS

The mean Barthel index was 47.7 and the mean Parker score was 3.5. 23% were found to be totally housebound and 26% were not able to perform any social activity. Only 18% were able to walk unaided. Patients with any medical complication had significantly higher mortality rates. Patients with extraarticular fractures had better mobility scores. Nursing home residents showed higher mortality rates but compared to patients coming from their own home the difference regarding Barthel and Parker scores remained non-significant.

CONCLUSION

This study documents the poor functional long-term outcome of geriatric patients with distal femoral fractures. In comparison to other fragility fracture patients it seems that this population is at higher risk to die in-hospital during their perioperative course. Medical complications have to be avoided as they were found to be associated with worse functional outcome and higher mortality rates. An osteoporosis therapy may be associated with reduced mortality rates also in these patients.