Cemented Versus Cementless Femoral Fixation for Total Hip Arthroplasty Following Femoral Neck Fracture in Patients Aged 65 and Older

Vancouver B Fractures After Using Cementless Femoral Fixation: A Single Center Experience

BACKGROUND

Cementless stems have been the predominant type of femoral component used for total hip arthroplasty (THA) in the United States for several decades. However, recent literature has reported an increased periprosthetic fracture (PPFx) rate and complications associated with these components, particularly among older patients. This study evaluated the incidence and outcome of Vancouver B PPFx after primary THA using cementless stems.

METHODS

A single institution's database was used to identify 12,400 primary THAs performed from 2009 through 2023. The mean age at surgery was 64 years, and 57% of THAs were performed among women. All postoperative PPFx were identified, and those classified as Vancouver B were evaluated for treatment method and secondary reoperations.

RESULTS

Among 72 postoperative PPFx, 34 were classified as Vancouver B for an overall rate of 0.3% (34 of 12,400). The median time from THA to Vancouver B PPFx was 33 days. Patients aged > 75 years at surgery had a higher rate of Vancouver B PPFx (0.6%, 13 of 2,094) compared to patients aged 18 to 75 years at surgery (0.2%, 21 of 10,306, P < 0.001). Type C3 triple-taper collared titanium stems had a lower fracture rate (0.1%, four of 4,748) compared to Type A flat taper stems (0.7%, 23 of 3,105, P < 0.001). In patients over 75 at surgery, Type C3 stems had a lower fracture rate (0.3%, three of 923) compared to Type A stems (1.5%, seven of 472, P = 0.04). There were 28 patients who had Vancouver B fractures (82%) who underwent reoperation. Secondary reoperations were performed among 25% (seven of 28) of THAs, and three of these involved periprosthetic joint infection.

CONCLUSIONS

Consistent with other reports, the Vancouver B PPFx rate was higher in patients aged > 75 years at surgery. At our institution, Type C3 triple-taper collared titanium stems lowered the PPFx fracture rate in all age groups, including those over age 75 years at surgery. Secondary reoperations remain highly morbid to patients.

Does Stem Design Affect the Incidence of Periprosthetic Femoral Fractures in Arthroplasty for Femoral Neck Fractures? A Secondary Analysis of the HEALTH Trial

BACKGROUND

The aim of this study was to evaluate how stem design influences the risk of periprosthetic femoral fractures (PFFs) after hemiarthroplasty (HA) and total hip arthroplasty for femoral neck fractures.

METHODS

We performed a secondary analysis of the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty trial, a multicenter, prospective, randomized control trial that assessed total hip arthroplasty versus hemiarthroplasty for low-energy femoral neck fractures. Between 1,374 patients (414 men, 960 women) that were assessed, 72 sustained PFFs (5.2%). Intraoperative PFFs were recorded in 42 patients, early postoperative PFFs in 15 and late PFFs in 15 patients. The incidence of PFFs was compared between cemented and cementless stems. Within the cemented group (n = 896), we analyzed the effect of taper-slip (n = 482) versus composite-beam (n = 414) designs, while within the cementless group (n = 478), we assessed the impact of single-wedged (n = 206) versus metaphyseal-filling stems (n = 272). The role of collars (n = 87) was also examined within the press-fit stems. Clinical outcomes were recorded with the Western Ontario and McMaster Universities Arthritis Index RESULTS: Cemented stems had a significantly lower incidence of PFFs than their cementless counterparts (2.6 versus 10.3%, P < 0.001). There was no difference in fracture rates between taper-slip and composite-beam stems (2.3 versus 2.9%, P > 0.05). Most of the composite-beam PFFs occurred intraoperatively (75%), while most of the taper-slip PFFs occurred late (55%). There was no difference between the. press-fit stems, while the presence of a collar did not show protective results (P > 0.05). Patients who underwent HA with taper-slip stems demonstrated inferior Western Ontario and McMaster Universities Arthritis Index scores and higher incidence of reoperation for pain than those treated with composite-beam stems (2.6 versus 0.4%, P = 0.048).

CONCLUSIONS

Cementless stems have a high PFF rate, regardless of the stem type or presence of collar. Taper-slip stems are responsible for late fractures, raising concerns about their performance in the long term. Patients treated with HA may present a higher risk of reoperation for pain when taper-slip stems are used.

Survivorship and Outcomes of Hip Arthroplasty for Elective Care versus Fracture in Patients Who Have Solid Organ Transplant: Lung Transplant Patients Do Worse

BACKGROUND

With continued improvement in patient outcomes following solid organ transplant (SOT), more SOT recipients may benefit from hip arthroplasty. This study sought to compare the perioperative complications and survivorship of SOT recipients undergoing hip arthroplasty for elective care versus for fracture.

METHODS

A single-institution retrospective review yielded 95 hip arthroplasty procedures (80 patients) performed between August 2016 and May 2023, with a mean follow-up of 35 months. The most common SOT was liver (47%), followed by kidney (31%) and lung (23%). Cases with an elective indication (69 hips) were compared to those with traumatic indications (26 hips). Perioperative complications and patient survivorship were compared between the groups and by transplant type.

RESULTS

Patient mortality at 1 year was 19.2% for the fracture group compared to 1.4% for the elective group (P = 0.006). For elective care, lung transplant recipients had a higher incidence of postoperative mortality at the final follow-up (27%) when compared to the liver (7%) and renal (0%) (P = 0.044). Hospital length of stay was less in the elective group (2.7 ± 3.1 versus 16.3 ± 21.2 days, P = 0.002), and more elective patients were discharged to home (85 versus 42%, P < 0.001), but there was no difference in the rate of 90-day hospital readmission (P = 0.91) or orthopaedic complications (13 versus 12%, P = 1.0). For fracture care, a preoperative surgical delay greater than 48 hour was more frequently observed for lung compared to liver transplant recipients (83 versus 13%, P = 0.010).

CONCLUSIONS

Recipients of SOT undergoing hip arthroplasty for fracture experience longer hospitalizations and increased 1-year mortality compared to elective cases with a similar rate of orthopaedic complications and hospital readmissions. When evaluating by SOT type, lung transplant patients may have increased surgical delays for fracture care and postoperative mortality for elective care.

LEVEL OF EVIDENCE

Level III.

Total Knee Arthroplasty Revision in the Setting of Periprosthetic Joint Infection Resulting in Bone Cement Implantation Syndrome (BCIS), Pulseless Electrical Activity (PEA) Arrest, and Intraoperative Death: A Case Report and Literature Review

An 87-year-old female with a history of total knee arthroplasty (TKA) presented to the emergency department (ED) for left knee pain in the setting of recent methicillin-sensitive Staphylococcus aureus (MSSA) sepsis of unknown origin. She was subsequently diagnosed with a complicated symptomatic periprosthetic joint infection of her left TKA hardware and was admitted for TKA revision following an orthopedic surgery consultation. Upon arrival at the operating room (OR), standard American Society of Anesthesiology (ASA) monitors were applied. These included non-invasive blood pressure, electrocardiogram (ECG), pulse oximeter, and an esophageal temperature probe. The patient then underwent induction of general endotracheal anesthesia (GETA) without significant hemodynamic compromise. Intraoperatively, the patient tolerated the removal of her infected hardware without major complication but upon placement of the methyl methacrylate (MMA), commonly referred to as bone cement, the patient had an acute drop in her end-tidal carbon dioxide (EtCO2) and then developed significant bradycardia and hypotension. Despite rapid detection and treatment, the patient continued to collapse hemodynamically and was noted to be pulseless and in pulseless electrical activity (PEA) arrest on ECG. Cardiopulmonary resuscitation (CPR) was immediately started per the Advanced Cardiac Life Support (ACLS) algorithm. Roughly after 45 minutes of continuous CPR and multiple doses of 1 mg epinephrine, it was determined that the patient had suffered a catastrophic and fatal intraoperative event. A team decision was made to stop providing any lifesaving interventions. This patient's presentation is consistent with bone cement implantation syndrome (BCIS), an uncommon phenomenon that remains poorly understood. Two leading models for BCIS described in the literature are the monomer-mediated and embolus-mediated models. However, further research into BCIS is warranted to better understand its pathophysiology, incidence, as well as potential prophylactic measures, including the use of cementless arthroplasty. This complicated and fatal case serves as a reminder of the morbidity and mortality associated with BCIS and underscores that anesthesiology teams must remain vigilant and prepared during orthopedic joint procedures.