Evaluating the Functional and Psychological Outcomes Following Periprosthetic Femoral Fracture After Total Hip Arthroplasty

Outcomes of revisions and fixations following periprosthetic fractures around the hip: a retrospective service evaluation

Background

Our study aims to report clinical outcomes of revision and ORIF for managing periprosthetic proximal femur fractures (PPFFs).

Materials & methods

We conducted a two-year retrospective analysis at a level 2 trauma centre, focusing on surgically managed PPFFs from primary and revised total hip and hemiarthroplasties. Primary outcomes were the one-year reoperation rate and mortality rate following revision or ORIF. We also specifically analysed B2 fracture management. Secondary outcomes were complication rates, time to surgery, length of hospital stay, transfusions and critical care requirements.

Results

67 patients were included, 44 (66 %) of whom were female. Mean age at operation was 83 years. Among them, 27 (40 %) had revision and 40 (60 %) had ORIF. One year reoperation rate was 11.11 % for revision and 7.50 % for ORIF. One year mortality rate was 25.93 % for revision and 10 % for ORIF. The overall complication rate was 29.63 % for revision and 7.50 % for ORIF. Time to surgery (89 and 77 h) and length of hospital stay (18 and 17 days) were similar in both groups.B2 fractures, which constituted 48 (71.64 %) of the cases, had a higher proportion of revision surgeries (27) compared to ORIF (21). For B2 fractures, revision was associated with higher reoperation and mortality rates as well as a significantly greater complication rate compared to ORIF.

Conclusion

PPFFs present a substantial healthcare challenge. Improving clinical outcomes for PPFF patients is crucial. This study highlights that ORIF may yield better outcomes for B2 fractures, when anatomical reduction is feasible. (249 words).

Revision for initial periprosthetic femur fracture increases likelihood of subsequent fracture in total hip arthroplasty

Background

Although a rare complication, periprosthetic fractures (PPF) following total hip arthroplasty (THA) are becoming more common. Revision THA (rTHA) for PPF is associated with high failure rates, and there is a paucity of literature reporting how often there is a subsequent PPF in these patients. This study aimed to determine the rate of femoral re-fracture following rTHA in patients with an initial PPF after primary THA.

Methods

The retrospective study identified 2044 patients who underwent rTHA between 2017 and 2023. Propensity score-matched cohort analysis was conducted to control for demographic variables. The primary outcome was the re-fracture rate and survivability of those patients who were revised for PPF.

Results

There were 183 patients who sustained an initial PPF and underwent subsequent rTHA. Of these patients, five (2.7 %) sustained re-fracture of the femur. After matching, there was a 3.7 % re-fracture rate in patients revised for an initial PPF compared to those who were not revised for PPF (0.37 %, P = 0.017). The 1-year re-fracture-free survivability of patients revised for initial PPF was 95.9 %, which was significantly lower compared to patients revised for non-PPF indications (99.6 %; P = 0.008). Older patients, women, elevated Charlson Comorbidity Index (CCI), and posterior approach during rTHA were found to be risk factors for PPF (P < 0.001).

Conclusion

Patients who were revised for an initial PPF had nearly a 10 times increased risk of re-fracturing compared to patients revised for other indications in THA. However, the similar readmission and failure rates and 1-year implant survivorship suggest comparable outcomes. Further analysis with a larger cohort and more outcome events is necessary.

The growing burden of periprosthetic fractures after total hip arthroplasty: identifying overall trends and at-risk groups

Rates of periprosthetic fracture (PPF) after total hip arthroplasty (THA) have doubled since 2010, especially among those with osteoporosis, those under the age of 50, and those with Medicaid insurance. Further work must be done to implement prevention strategies and mitigate the rise in PPF after THA in the United States.

PURPOSE

Periprosthetic fractures (PPFs) following primary total hip arthroplasty (THA) contribute significantly to postoperative morbidity, mortality, and healthcare costs. With an aging population and increased utilization of THA in younger patients, there is potential for rates of PPF to increase accordingly. The purpose of this study was to evaluate recent trends in PPF incidence after primary THA and to identify the most affected sub-populations.

METHODS

A total of 500,078 patients who underwent primary THA during the years 2010-2019 were identified in a national administrative claims database. Incidence rates of 2-year PPF and a compounded annual growth rate (CAGR) were calculated. A sub-analysis was conducted to stratify baseline characteristics including age, biological sex, and risk factors for PPF. Linear regression was performed to assess trends.

RESULTS

The total rate of 2-year PPF demonstrated a + 7.05% annual growth from 2010 to 2019. The most pronounced increases occurred in patients less than 50 years old (CAGR =  + 9.24%, p = 0.005), with comorbid osteoporosis (CAGR =  + 13.7%, p = 0.001), vitamin D deficiency (CAGR =  + 12.2%, p = 0.002), and Medicaid insurance (CAGR =  + 7.19%, p < 0.001).

CONCLUSIONS

Rates of PPF following primary THA have nearly doubled since 2010, with the greatest increases among patients with poor bone health, particularly those with osteoporosis and poor underlying bone health. These findings underscore the growing burden of osteoporosis-related complications and highlight the urgent need for improved prevention strategies, including early identification and preoperative bone health optimization.

LEVEL OF EVIDENCE

III.

Who breaks their hip? A decade of traumatic hip fracture data

Aims & objectives

Hip fractures lead to significant morbidity, mortality, and healthcare costs, particularly in elderly populations. Understanding the mechanisms underlying these fractures is crucial for developing targeted prevention strategies and counseling patients.

Methods

The National Electronic Injury Surveillance System (NEISS) was utilized to identify a cohort of 25,068 hip fractures from 2013 to 2022. The inclusion criteria mandated classification as a lower trunk fracture and explicit mention of hip fracture in the narrative. Patient age, race, sex, incident location, the time of year, and associated consumer products were compared using 95% confidence intervals and Chi-Squared tests of independence.

Results

A total of 25,068 hip fracture patients were included in this study. Females were more likely to fracture their hip (P < .001) representing 68.4% (95% CI 67.8%-69.0%) of all fractures. Patients were most likely to injure themselves at home (P < .001), accounting for 62.0 % (95% CI 61.4%-62.6%) of fractures. Falls to the floor represented 36.0 % (95% CI 35.4%-36.6%) of fractures, while fractures related to beds, stairs, and chairs emerged as other prevalent mechanisms at 11.2% (95% CI 10.8%-11.6%), 7.9% (95% CI 7.5%-8.2%), and 5.4% (95% CI 5.1%-5.7%), respectively. In the 50-60 age group, stairs present a prominent risk, representing 12.4% (95% CI 10.6%-14.5%) of fractures. Younger individuals suffered fractures most commonly due to high energy activities, such as falls from ladders, bicycles, and stairs (P < .001).

Conclusion

While falls remain the chief cause of hip fractures, many of these injuries stem from overlooked mechanisms. The heightened risk associated with falls from beds and chairs in the elderly, stair-related injuries in middle-aged individuals, and high-force modalities in younger people, highlights the necessity for tailored preventive measures. Providers should counsel their patients on risk reduction measures within the home, while Medicare and other insurers must work to expand coverage for these same measures.

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

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

What Are the Mortality, Infection, and Nonunion Rates After Periprosthetic Femoral Fractures in the United States?

BACKGROUND

Periprosthetic femoral fractures are a serious complication that put a high burden on patients. However, comprehensive analyses of their incidence, mortality, and complication rates based on large-registry data are scarce.

QUESTIONS/PURPOSES

In this large-database study, we asked: (1) What is the incidence of periprosthetic femoral fractures in patients 65 years and older in the United States? (2) What are the rates of mortality, infection, and nonunion, and what factors are associated with these outcomes?

METHODS

In this retrospective, comparative, large-database study, periprosthetic femoral fractures occurring between January 1, 2010, and December 31, 2019, were identified from Medicare physician service records encompassing services rendered in medical offices, clinics, hospitals, emergency departments, skilled nursing facilities, and other healthcare institutions from approximately 2.5 million enrollees. These were grouped into proximal, distal, and shaft fractures after TKA and THA. We calculated the incidence of periprosthetic femur fractures by year. Incidence rate ratios (IRR) were calculated by dividing the incidence in 2019 by the incidence in 2010. The Kaplan-Meier method with Fine and Gray subdistribution adaptation was used to calculate the cumulative incidence rates of mortality, infection, and nonunion. Semiparametric Cox regression was applied with 23 measures as covariates to determine factors associated with these outcomes.

RESULTS

From 2010 to 2019, the incidence of periprosthetic femoral fractures increased steeply (TKA for distal fractures: IRR 3.3 [95% CI 1 to 9]; p = 0.02; THA for proximal fractures: IRR 2.3 [95% CI 1 to 4]; p = 0.01). One-year mortality rates were 23% (95% CI 18% to 28%) for distal fractures treated with THA, 21% (95% CI 19% to 24%) for proximal fractures treated with THA, 22% (95% CI 19% to 26%) for shaft fractures treated with THA, 21% (95% CI 18% to 25%) for distal fractures treated with TKA , 22% (95% CI 17% to 28%) for proximal fractures treated with TKA, and 24% (95% CI 19% to 29%) for shaft fractures treated with TKA. The 5-year mortality rate was 63% (95% CI 54% to 70%) for distal fractures treated with THA, 57% (95% CI 54% to 62%) for proximal fractures treated with THA, 58% (95% CI 52% to 63%) for shaft fractures treated with THA, 57% (95% CI 52% to 62%) for distal fractures treated with TKA , 57% (95% CI 49% to 65%) for proximal fractures treated with TKA, and 57% (95% CI 49% to 64%) for shaft fractures treated with TKA. Age older than 75 years, male sex, chronic obstructive pulmonary disease (HR 1.48 [95% CI 1.32 to 1.67] after THA and HR 1.45 [95% CI 1.20 to 1.74] after TKA), cerebrovascular disease after THA, chronic kidney disease (HR 1.28 [95% CI 1.12 to 1.46] after THA and HR 1.50 [95% CI 1.24 to 1.82] after TKA), diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis were clinical risk factors for an increased risk of mortality. Within the first 2 years, fracture-related infections occurred in 5% (95% CI 4% to 7%) of patients who had distal fractures treated with THA, 5% [95% CI 5% to 6%]) of patients who had proximal fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had shaft fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had distal fractures treated with TKA , 7% (95% CI 5% to 9%) of patients who had proximal fractures treated with TKA, and 6% (95% CI 4% to 8%) of patients who had shaft fractures treated with TKA. Nonunion or malunion occurred in 3% (95% CI 2% to 4%) of patients with distal fractures treated with THA, 1% (95% CI 1% to 2%) of patients who had proximal fractures treated with THA, 2% (95% CI 1% to 3%) of patients who had shaft fractures treated with THA, 4% (95% CI 3% to 5%) of those who had distal fractures treated with TKA, , 2% (95% CI 1% to 4%) of those who had proximal fractures treated with TKA, and 3% (95% CI 2% to 4%) of those who had shaft fractures treated with TKA.

CONCLUSION

An increasing number of periprosthetic fractures were observed during the investigated period. At 1 and 5 years after periprosthetic femur fracture, there was a substantial death rate in patients with Medicare. Conditions including cerebrovascular illness, chronic kidney disease, diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis are among the risk factors for increased mortality. After the surgical care of periprosthetic femur fractures, the rates of fracture-related infection and nonunion were high, resulting in a serious risk to affected patients. Patient well-being can be enhanced by an interdisciplinary team in geriatric traumatology and should be improved to lower the risk of postoperative death. Additionally, it is important to ensure that surgical measures to prevent fracture-related infections are followed diligently. Furthermore, there is a need to continue improving implants and surgical techniques to avoid often-fatal complications such as fracture-associated infections and nonunion, which should be addressed in further studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Promoting cemented fixation of the femoral stem in elderly female hip arthroplasty patients and elderly hip fracture patients: a retrospective cohort study from the Norwegian Arthroplasty Register and the Norwegian Hip Fracture Register

BACKGROUND AND PURPOSE

Uncemented stems increase the risk of revision in elderly patients. In 2018, we initiated a national quality improvement project aiming to increase the proportion of cemented stems in elderly female total hip arthroplasty (THA) and hip fracture hemiarthroplasty (HA) patients. We aimed to evaluate the association of this project on the frequency of cemented stems and the risk of secondary procedures in the targeted population.

METHODS

10,815 THAs in female patients ≥ 75 years in the Norwegian Arthroplasty Register and 19,017 HAs in hip fracture patients ≥ 70 years in the Norwegian Hip Fracture Register performed in 2015-2017 and 2019-2021 at all Norwegian hospitals were included in this retrospective cohort study. The quality improvement project was implemented at 19 hospitals (8,443 patients). 1-year revision risk (THAs) and reoperation risk (HAs) were calculated for uncemented and cemented stems by Kaplan-Meier and Cox adjusted hazard rate ratios (aHRRs) with all-cause revision/reoperation as main endpoint.

RESULTS

The use of cemented stem fixation in the targeted population increased from 26% to 80% for THAs and from 27% to 91% for HAs. For THAs, the 1-year revision rate decreased from 3.7% in 2015-2017 to 2.1% in 2019-2021 (aHRR 0.7, 95% confidence interval [CI] 0.5-0.9) at the intervention hospitals. For HAs, the reoperation rate decreased from 5.9% in 2015-2017 to 3.3% in 2019-2021 (aHRR 0.6, CI 0.4-0.8) at the intervention hospitals.

CONCLUSION

The quality improvement project resulted in a significant increase in the proportion of cemented stems and reduced risk of secondary procedures for both THAs and HAs.

Revision total hip arthroplasty for periprosthetic fracture: epidemiology, outcomes, and factors associated with success

The aging population and the increasing number of patients with primary total hip arthroplasties (THA) has equated to an increased incidence of periprosthetic fractures (PPF) of the hip. These injuries are a significant source of patient morbidity and mortality, placing a financial burden on healthcare systems worldwide. As the volume of PPF is expected to along with the growing volume of primary and revision THA, it is important to understand the outcomes and factors associated with treatment success. The choice of procedure is in large part guided by the help of the Vancouver Classification system, which is a valid and reproducible system that classifies fractures based on several factors including site of fracture, implant stability and bone stock. PPFs account for approximately 18% of revision THA (rTHA) procedures. rTHA for PPFs is commonly indicated in Vancouver B2 and B3 fractures, to bypass a lack of metaphyseal support with diaphyseal fixation. Such revisions are technically challenging and typically require urgent treatment, with inherent difficulties in patient optimization, leading to a notable rate of post-operative complications, re-revision and mortality. This article reviews epidemiology, health economics and risk factors for PPFs. It additionally reviews outcomes associated with rTHA for PPFs including peri-operative complications, indications for re-operation, rates of re-operation and rates of mortality. Finally, it aims to identify evidence-based factors that have been associated with successful management including modifiable patient-related factors, uncemented vs. cemented stems, stem design (porous coated stems vs. fluted tapered stems), modularity, dislocation and its impact on outcomes following rTHA and strategies for managing bone loss.

Aesthetic Results, Functional Outcome and Radiographic Analysis in THA by Direct Anterior, Bikini and Postero-Lateral Approach: Is It Worth the Hassle?

Total hip arthroplasty (THA) can be performed by several approaches such as direct anterior (DAA), direct lateral (DL) and postero-lateral (PL). Our study was conducted to compare among different approaches, such as DAA, bikini (BK) and PL, the aesthetic impact of the scar, differences in the position of prosthetic components and differences in functional rehabilitation outcomes. Materials and methods: Population, composed by 240 patients, was collected among patients treated for primary total hip arthroplasty (THA) from 1 January 2017 to 31 December 2021 and divided by surgical approach. Of these, 160 female patients were included in the current analysis, leaving 58 DAA, 52 BK patients and 50 PL patients. Demographic and clinical parameters were retrospectively collected: age, BMI, time of surgery, length of stay, Harris Hip Score (HHS) before and after surgery at 6 months and patient, intra/post-surgical complications and Patient and Observer Scar Assessment Scale (POSAS). Results and Discussion: Our results showed a better aesthetical result in BK group compared to DAA group and faster rehabilitation with the DAA compared to PL. Optimal cup positioning was reached both in PL approach and DAA approach. DAA showed no increase in complications compared to PL approach and offered a faster recovery. Bikini approach is an alternative to the standard DAA approach and can be proposed for patients where a better aesthetic result is desired in addition to better functional recover.