The Influence of Dorr Type and Femoral Fixation on Outcomes Following Total Hip Arthroplasty for Acute Femoral Neck Fractures: A Multicenter Study

Risk factors for periprosthetic femoral fractures following hip arthroplasty: a systematic review and meta-analysis

INTRODUCTION

Periprosthetic femoral fracture (PPFF) is a serious complication following hip arthroplasty. The objective of this study was to determine the risk factors for PPFF following hip arthroplasty from existing studies.

METHODS

A comprehensive systematic search was performed in 4 databases: Pubmed, Embase, Web of Science, and Cochrane Library. The last search was carried out on 26th July 2024. We focused on identifying risk factors for PPFF following hip arthroplasty. Study eligibility required PPFF as an outcome and reporting of associated risk factors. Quality assessment was performed using the Newcastle-Ottawa Scale (NOS), with evidence certainty evaluated via Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Meta-analyses employed both fixed-effect and random-effects models to pool odds ratios for identified risk factors.

RESULTS

Out of 1553 articles, 36 studies published between 2006 and 2024 were included. Risk factors associated with increased incidence of PPFF ranges from very Low to High. High-quality evidence supported the use of uncemented stems (Odds Ratio [OR]: 3.36, 95% Confidence Interval [95% CI]: 3.02-3.74), major teaching hospital (OR: 2.04, 95% CI: 1.37-3.05). Moderate-quality evidence: female gender (OR: 1.60, 95% CI: 1.43-1.78), morbid obesity (OR: 1.44, 95% CI: 1.01-2.16), higher Deyo-Charlson index (OR: 1.44, 95% CI: 1.18-1.77), rheumatoid arthritis (OR: 1.89, 95% CI: 1.16-3.06), femoral Dorr type C (OR: 4.23, 95% CI: 2.82-6.33). Low evidence: age > 70 years (OR: 1.67, 95% CI: 1.19-2.34), revision hip arthroplasty (OR: 2.60, 95% CI: 1.59-4.27). BMI > 30 and history of hip surgery are not the risk (very low). Diagonized as osteoarthritis before surgery is a protective factor (OR:0.51, 95%CI: 0.40-0.65, quality = High).

CONCLUSION

This meta-analysis provided some low-to-high evidence about the risk of PPFF following hip arthroplasty. It's recommended that clinicians consider these risk factors when evaluating patients for hip arthroplasty and take steps to mitigate their impact, like optimizing patients health preoperatively, using cemented stems, and monitoring high-risk patients closely.

Age and sex-specific differences of the intrafemoral and intratibial morphology using the Citak classification in patients undergoing total knee arthroplasty

PURPOSE

Unlike established knee phenotype classifications, the recently introduced Citak classifications describe the intrafemoral and intratibial knee morphology. The aim of this study was to evaluate the distribution of Citak types A, B and C of the distal femur and proximal tibia in a large cohort and to examine the influence of age, body mass index (BMI) and knee phenotypes.

METHODS

A total of 8739 patients undergoing primary total knee arthroplasty (TKA) were included in this study. The coronal plane alignment of the knee (CPAK) and functional knee phenotypes were assessed on standardised preoperative long leg radiographs (LLR) using a validated artificial intelligence (AI) software. The Citak classification was measured manually, and BMI, sex and age were compared between the different Citak types.

RESULTS

The most common morphotypes were Citak type B of the distal femur (men: 1362 (46.5%); women 3042 (52.4%)) and Citak type C of the proximal tibia (men: 2605 (88.9%); women 5406 (93.0%)). Women with Citak type C of the distal femur (mean age 71.45a; p < 0.001) and proximal tibia (mean age 69a; p < 0.001) were significantly older, while no age differences were observed among men. Citak type A of the distal femur and proximal tibia had an overall higher BMI in both men and women.

CONCLUSION

The Citak types of the distal femur and the proximal tibia are age, sex and BMI dependent in patients undergoing primary TKA. Recognising these morphological variations might improve preoperative planning and implant selection in TKA, potentially improving patient outcomes. The Citak classification is useful to further characterise various knee morphotypes.

LEVEL OF EVIDENCE

Level III.

How does the Dorr classification of proximal femur affect the total hip arthroplasty of hemophilic patients: a retrospective study

Patients with hemophilia (PWH) constantly suffer hemarthrosis due to the lack of coagulation factors, resulting in progressive deformity of the hip joint. Currently, there is a dearth of understanding on the unusual morphology of proximal femur in PWH. To explore how does the Dorr classification of proximal femur affect the total hip arthroplasty (THA) of PWH, we conducted a retrospective study on PWH with different Dorr classifications who underwent THA. The retrospective study comprises data of adult patients who received THA from 2018 to 2022 in the research center. Patients with a diagnosis of hemophilic arthritis and received THA were included and divided into three groups according to Dorr classification. The X-ray images were acquired before the surgery to determine the Dorr classification. The surgical time, surgical blood loss, laboratory examinations post-operation including hemoglobin (HB), total protein (TP), activated partial thromboplastin time (APTT), D-dimer (D2), C-reactive protein level (CRP), erythrocyte sedimentation rate (ESR), and functional evaluations 1 year after surgery including visual analogue scale (VAS), Harris hip score (HHS), range of motion (ROM) were collected. Kolmogorov-Smirnov test is used to test data normality, and t-test is performed by SPSS 20. P < 0.05 is considered statistically significant. 33 PWH are included in the study and have finished follow-up. All cases are male patients. Among the 33 hips, 19 (57.6%) are classified to Dorr A, and 12 (36.4%) are Dorr B, and only 2 (6%) are Dorr C. No significant difference is found in expanse, hospital stay, surgical time and total blood loss. PWH with Dorr A requires significant less coagulation factor than Dorr B and Dorr C. All Dorr types of hips present good recovery from the surgery according to the perioperative examinations including hemoglobin (HB), total protein (TP), activated partial thromboplastin time (APTT), D-dimer (D2), C-reactive protein level (CRP), erythrocyte sedimentation rate (ESR), and thigh circumference (TC). The 2-year follow-up demonstrates favorable functional rehabilitation according to functional evaluations including visual analogue scale (VAS), Harris hip score (HHS), and range of motion (ROM). In this study, we find that PWH tend to have higher prevalence of Dorr A than the general population. PWH with Dorr A requires smaller dosage to maintain the coagulation factor activity than the Dorr B and Dorr C. Additionally, all types of hip present favorable recovery after THA. Ultimately, the study supports that THA is an effective treatment for PWH with all Dorr classifications by alleviating the pain and improve the motor function.

[Surgical treatment strategies for periprosthetic femoral fractures of type Vancouver B]

BACKGROUND

The demographic shift is expected to lead to a further increase in the number of hip joint replacements. Accordingly, as has already been observed in recent years, a further increase in periprosthetic femoral fractures (PPF) is to be expected. PPF is now the third most common reason for revision surgery after hip arthroplasty.

OBJECTIVES

Taking into account the known risk factors for PPF, fracture treatment strategies are evaluated based on current evidence in order to make recommendations for practice.

METHODS

Narrative review.

RESULTS

Overall, the literature is very heterogeneous and evidence is lacking for many aspects. Numerous recommendations are based on non-randomized studies with low patient count. Mortality after PPF is high regardless of the treatment chosen. Age and bone quality influence the partly heterogeneous results and play a role in the treatment strategy. The use of both cemented and uncemented stems in revision surgery due to proximal PPF is frequently described in the literature. There are no significant differences in terms of outcome. The advantage of uncemented modular stems is currently not supported by the literature.

CONCLUSIONS

An individualized approach to the treatment of PPF is recommended, considering environmental factors and comorbidities. In geriatric patients, full weight-bearing of the lower extremity should be aimed for postoperatively to avoid complications.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

Narrative review.

RESULTS

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

CONCLUSIONS

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

The advantages of artificial intelligence-assisted total hip arthroplasty: A randomized controlled trial followed by 12 months

OBJECTION

The rapid advancement of artificial intelligence has brought significant breakthroughs to various medical disciplines，This study aimed to compare perioperative factors and postoperative hip function recovery in primary total hip arthroplasty (THA)by evaluating the use of an artificial intelligence (AI) preoperative planning system versus traditional two-dimensional X-ray planning.

PATIENTS AND METHODS

A total of 45 eligible patients underwent primary THA at Beijing Shijitan Hospital, Capital Medical University, between July 2022 and August 2022. The patients were randomly assigned to either the experimental group (n = 19) or the control group (n = 26). The experimental group utilized AI planning, while the control group employed traditional two-dimensional X-ray planning. Statistical analysis was performed to compare the accuracy of prosthesis prediction, operation time, intraoperative blood loss, frequency of intraoperative model testing, length of hospital stay, postoperative imaging data, and postoperative hip function scores. These comparisons were made to assess the effects of different preoperative planning methods on perioperative and postoperative hip function recovery.

RESULTS

The accuracy of preoperative planning for the acetabular and femoral sides in AI-assisted total hip arthroplasty was 84.2 % and 89.5 %, respectively, which was significantly better than that of the traditional two-dimensional X-ray planning group (P < 0.05). The operation time for AI-assisted total hip arthroplasty was 104.32 ± 18.10 min, which was shorter than that of the traditional two-dimensional X-ray planning group (P < 0.05). At 3 months post-operation, the grade of Harris score for hip function in the AI planning group was significantly better than that in the traditional two-dimensional X-ray planning group (P < 0.05). The average postoperative Harris score of the artificial intelligence group was higher than that of the traditional two-dimensional X-ray planning (P < 0.05).

CONCLUSION

Artificial intelligence-assisted total hip arthroplasty demonstrated superior accuracy in prosthesis prediction, shorter operation time, higher average Harris score at postoperative follow-up, and better hip function recovery at 3 months compared to traditional two-dimensional X-ray planning.

LEVEL OF EVIDENCE

III, case-control study.

Cemented Calcar-Guided Short-Stem Prostheses in Geriatric Patients: Short-Term Results from a Prospective Observational Study

Both cementless and cemented stems have exhibited favorable long-term outcomes in total hip arthroplasty. Nonetheless, in elderly patients, cemented hips offer an advantage due to their reduced risk of periprosthetic fractures. This study aimed to assess the initial outcomes of 28 patients who underwent unilateral cemented total hip arthroplasty utilizing a calcar-guided A2 stem (ARTIQO GmbH, Lüdinghausen, Germany). Various types of antibiotic-loaded bone cement were employed. During follow-up, we recorded demographic data and comorbidities and employed standardized clinical assessment tools, including the Harris Hip Score. Radiographic assessments included preoperative, postoperative, and follow-up imaging to evaluate subsidence, osteolysis, and bone resorption. The results indicated that among the 28 patients, 5 withdrew consent and 2 patients passed away from unrelated causes. Additionally, one prosthesis was explanted due to the undersizing of the cement stopper, which resulted in an inadequate cement mantle. As a result, 20 patients underwent a 1-year follow-up, revealing noteworthy enhancements in clinical scores, with no instances of radiolucent lines or osteolysis. No infections were detected. In summary, our short-term experience with this particular cemented short-stem design yielded promising results, exhibiting excellent functional outcomes, no aseptic loosening attributable to the stem, and no infections. Further clinical studies and registry data are essential to corroborate these findings.

Stress shielding following radial head arthroplasty: the impact of preoperative bone quality

BACKGROUND

We sought to assess if the medullary diameter to cortical width ratio (MD:CW), canal flair index (CFI), and canal fill (CF) of the proximal radius were associated with the presence of stress shielding (SS) after a MoPyC radial head arthroplasty.

MATERIALS AND METHODS

We conducted a retrospective, international, multicenter (4 centers) study. A total of 100 radial head arthroplasties in 64 women and 36 men with a mean age of 58.40 years ± 14.90 (range, 25.00-91.00) were included. Radiographic measurements, including MD:CW, CFI, CF, and postoperative SS were captured at a mean follow-up of 3.9 years ± 2.8 (range, 0.5-11).

RESULTS

SS was identified in 60 patients. Mean preoperative MD:CW, CFI, and CF were 0.55 ± 0.09, 1.05 ± 0.18, and 0.79 ± 0.11, respectively. The presence of SS was significantly associated with MD:CW (adjusted odds ratio = 13.66; P = .001), and expansion of the stem (adjusted odds ratio = 3.78; P = .001). The amount of the SS was significantly correlated with expansion of the stem (aβ 4.58; P < .001).

CONCLUSIONS

Our study found that MD:CW was an independent risk factor of SS after MoPyc radial head arthroplasty. Autoexpansion of the MoPyc stem significantly increased the risk of SS and its extent. Further studies involving multiple implants designs are needed to confirm the preliminary observations presented in the current study.

Medial Calcar Density Measured via Opportunistic Computed Tomography Is Well Represented by the Dorr C Classification

Introduction The canal-to-calcar isthmus (CC) ratio has been previously correlated with proximal femur osteology, but its relationship with bone density is not well established. Our purpose was to assess the relationship between femoral bone density, measured on opportunistic quantitative CT in Hounsfield units (HU), and CC ratio. Methods A total of 148 THA patients were included. The CC ratio was measured on anteroposterior hip radiographs. Using perioperative CT scans, a 1 cm diameter area was identified on a single mid-coronal slice in the medial calcar just proximal to the intertrochanteric ridge. The mean HU was calculated in this region to represent calcar bone density. Results Twenty-four percent (n = 35) of patients were classified as Dorr A (average CC ratio 0.47 [0.45; 0.48]), 67% (n = 96) as Dorr B (0.62 [0.55; 0.68]), and 11% (n = 17) as Dorr C (0.78 [0.77; 0.80]). There was a significant difference between Dorr A and Dorr C femurs (769 (144) vs. 588 (154) HU) as well as between B and C femurs (718 (166) vs. 588 (154) HU). The CC ratio was correlated with calcar bone density on CT (-0.370). Conclusion CC ratio is correlated with bone density determined by HU measurements on an opportunistic quantitative computed tomography scan, and bone density HU values were able to accurately differentiate bone density in Dorr A and B from Dorr C femurs. These findings suggest that the CC ratio is a reliable measurement to predict bone density in Dorr C femurs. Therefore, arthroplasty surgeons can confidently use the Dorr classification for patients with Dorr C femurs when preoperatively planning for THA.

Difference in early all-cause mortality among patients having hip arthroplasty a Swedish perioperative registry study 2013-2022

INTRODUCTION

Hip arthroplasty is a common orthopaedic procedure worldwide. There is an ongoing debate related to the fixation and anaesthesia impact on the 30-day mortality, particularly in the aging population with higher American Society of Anaesthesiology (ASA) Physical-Status.

AIM

To study the 30-day all-cause mortality in patients undergoing primary hip arthroplasty, with regards to the impact of age, ASA-class, anaesthesia techniques, indication for surgery and fixation techniques.

MATERIALS AND METHODS

Perioperative data for primary hip arthroplasty procedures for osteoarthritis and hip fractures registered in the Swedish Perioperative Registry (SPOR) between 2013 and June 2022 were collected. Binary logistic regressions were performed to assess the impact of age, ASA-class, anaesthetic technique, indication for surgery and fixation on odds ratio for 30-day mortality in Sweden.

RESULTS

In total, 79,114 patients, 49,565 with osteoarthritis and 29,549 with hip fractures were included in the main study cohort. Mortality was significantly higher among hip fracture patients compared with osteoarthritis, cumulative 8.2% versus 0.1% at 30-days respectively (p < 0.001). Age above 80 years (OR3.7), ASA 3-5 (OR3.3) and surgery for hip fracture (OR 21.5) were associated with significantly higher odds ratio, while hybrid fixation was associated with a significantly lower odds ratio (OR0.4) of 30-day mortality. In the same model, for the subgroups of osteoarthritis and hip fracture, only age (OR 3.7) and ASA-class (OR 3.3) had significant impact, increasing the odds ratio for 30-day mortality. Hemi arthroplasty was commonly used among the hip fracture patients 20.453 (69.2%), and associated with a significantly higher odds ratio for all-cause 30-day mortality as compared to total hip arthroplasty when adjusting for age and ASA-class and fixation 2.3 (95%CI 1.9-2.3, p < 0.001).

CONCLUSIONS

All-cause 30-day mortality associated with arthroplasty differed significantly between the two cohorts, hip fracture, and osteoarthritis (8.2% and 0.1% respectively) and mortality expectedly increased with age and higher ASA-class. Anaesthetic method and cement-fixation did not impact the odds ratio for all-cause 30-day mortality after adjustment for age and ASA-class.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Calcar-guided short-stem total hip arthroplasty in fractures of the femoral neck: a prospective observational study of 68 hips

INTRODUCTION

The indications for cementless short-stem total hip arthroplasty (THA) have been expanded due to encouraging results. However, no evidence in cases of femoral neck fractures (FNFs) is available. We aimed to prospectively obtain data on the safety and the clinical outcomes of a cementless calcar-guided short stem in patients with FNFs.

MATERIALS AND METHODS

We conducted a prospective observational study of 68 patients diagnosed with FNFs who underwent short-stem THA between 2016 and 2019 with a calcar-guided stem. Complications during follow-up leading to revision were documented, and patient reported outcome measurements recorded. Stem migration was analyzed using the Einzel-Bild-Röntgen-Analysis Femoral Component Analysis software.

RESULTS

The mean follow-up was 33.8 ± 14.8 months. The patient mortality at last follow-up was 10.6%. Two patients required stem revision, due to periprosthetic fracture and late aseptic loosening, respectively, corresponding to 96.2% stem survival. Survivorship for the endpoint of revision for any reason was 91.1% at 6 years. All revisions occurred in females. The mean Harris Hip Score at the last follow-up was 93.0 ± 8.9. The mean axial migration at last follow-up was 1.90 ± 1.81 mm. No significant influence on migration was found regarding gender, age, weight, and body mass index.

CONCLUSIONS

The clinical and radiological findings were satisfying and most patients benefited from the minimally invasive procedure. However, as for conventional THA as well, implant survivorship and mortality were markedly worse compared to results regarding osteoarthritis. Especially in elderly female patients with FNF, cementless short-stem THA is a concern and a cemented THA should be the first choice.

Novel radiologic indices for stem type decision in total hip arthroplasty in patients with metaphyseo-diaphyseal mismatched Dorr A proximal femur

BACKGROUND

In metaphyseo-diaphyseal (M-D) mismatched Dorr A femurs, it is difficult to achieve proper fixation with a type 1 stem. Proper interpretation of the geometry of the femur is integral at the preoperative stage in an M-D mismatched femur, but there has been a scarcity of studies on the radiologic indices. Therefore, we analyze the previous radiologic indices and suggest the novel ones for M-D mismatched femurs.

METHODS

Our study was a retrospective review of preoperative radiographs of patients who underwent total hip arthroplasty with the smallest type 1 stem or with type 3 C stem at a single institution from July 2014 to March 2022. A Type 3 C stem was used when the smallest type 1 stem failed to achieve metaphyseal fixation. One hundred twenty-six patients were categorized into two main groups. Canal-flare index, canal-calcar ratio, modified morphological cortical index, and two novel indices (lesser trochanter-to-distal ratio-α and -β [LDR-α and -β]) were assessed on preoperative pelvic radiographs.

RESULTS

Multivariate and ROC analysis demonstrated that high LDR-β (Exp[B]: 485.51, CI: 36.67-6427.97, p < 0.001) was associated with a more mismatched tendency group and had clinically acceptable discriminatory power (AUC: 0.765, CI: 0.675-0.855, p < 0.001) between the two cohorts.

CONCLUSION

Correct assessment of preoperative femoral morphology would be fundamental in the selection of a suitable stem. The ratio based on 3 cm below the lesser trochanter of the femur seemed crucial. We recommend evaluating the newly described radiological index preoperatively in M-D mismatched Dorr A femur for planning precisely and selecting a proper stem.