One year after proximal or distal periprosthetic fracture of the femur -two conditions with divergent outcomes?

Distal femoral replacement for the treatment of periprosthetic distal femoral fractures around a total knee arthroplasty: a meta-analysis

Background

Periprosthetic fracture is a rare complication of arthroplasty but can have devastating consequences for the patient and presents a complex surgical challenge. Locking compression plate and retrograde intramedullary nail are both widely accepted surgical fixation techniques for distal femoral periprosthetic fractures around a total knee arthroplasty. Although there is still a need for further high-quality research into both techniques, there is even less literature concerning the use of distal femoral replacement to treat distal femoral periprosthetic fractures. Interest has been piqued in distal femoral replacements for the treatment of distal femoral periprosthetic fractures due to the theoretical advantages of immediate post-operative weight-bearing and lack of dependence on fracture union, but there are still understandably reservations about performing such an extensive and invasive procedure when an accepted alternative is available. This meta-analysis aims to evaluate the current literature to compare the complication rates and return to pre-operative ambulatory status of distal femoral replacement and locking compression plate.

Method

A literature search was performed to identify articles related to the management of distal femoral periprosthetic fractures around a total knee arthroplasty in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Methodological quality was assessed using the methodological index for non-randomized studies (MINORS) criteria. Articles were reviewed, and data extracted for analysis.

Results

Five articles met the inclusion criteria, reporting on 345 periprosthetic fractures. The overall rates of complications for distal femoral replacement and locking compression plate were: re-operation (6.1% vs 12.1%), infection (3.0% vs 5.3%), mortality (19.7% vs 19.3%), and return to pre-operative ambulatory status (60.9% vs 71.8%) (respectively).

Conclusion

This meta-analysis shows no statistically significant difference in the rates of re-operation, infection, mortality or return to pre-operative ambulatory status when comparing distal femoral replacement to locking compression plate.

Periprosthetic fractures are osteoporotic fractures: missed opportunities for osteoporosis diagnosis

Joint replacement surgery is common in older adults, leading to increasing periprosthetic fracture (PPFx) occurrence. We reviewed all PPFx seen over a 4-year period at an academic hospital. Clinical osteoporosis could be diagnosed based on existing data in 104 (67%) at the time of PPFx. Periprosthetic fractures are generally osteoporosis-related.

PURPOSE

Periprosthetic fractures (PPFx) cause morbidity, mortality, and cost. This study's purpose was to describe osteoporosis-related data available at the time of PPFx.

METHODS

The electronic medical record (EMR) of PPFx patients seen over 4 years in a university orthopedic practice were reviewed. Demographic data and osteoporosis relevant parameters were collected. Prior DXA studies were reviewed, and L1 Hounsfield unit (HU) measurements were performed on CT scans obtained within 2 years before PPFx. Clinical osteoporosis was defined as prior diagnosis, prescribed osteoporosis treatment, T-score ≤  - 2.5, HU ≤ 100, or prior fracture.

RESULTS

Records of 156 PPFx patients (115 F/41 M), mean (SD) age 75.4 (11.9), were reviewed. Almost all 153/156 (98%) of these fractures were femoral. Falls caused 139 (89%); 12 (8%) were spontaneous. Mean time post-arthroplasty was 7.9 (6.3) years. Prior fragility fracture(s) occurred in 72 (46%); 14 were PPFx. Osteoporosis was previously diagnosed in 45 (29%) and medications prescribed in 41 (26%). Prior to PPFx, DXA data were available in 62, mean (SD) lowest T-score was - 1.9 (0.9) and was ≤  - 2.5 in 19. CT data were available in 46; mean (SD) L1 HU was 79.0 (29.4) and was ≤ 100 in 35. Based on existing data, clinical osteoporosis could have been diagnosed in 104 (67%) at the time of PPFx.

CONCLUSION

Periprosthetic fractures are osteoporosis-related. They occur in older adults, often female, and result from falls; BMD, when assessed, is low. Data available at the time of PPFx often allows osteoporosis diagnosis; this should prompt evaluation and pharmacologic treatment consideration.

Minimally invasive surgery of femoral periprosthetic fractures increases the rate of consolidation and decreases time to bone healing without a higher rate of complications

BACKGROUND

Knee periprosthetic femoral fractures (KPPFF) are becoming more frequent due to the increasing number of arthroplasties and the aging population, for whom maintaining autonomy and function remains a challenge. The use of locking plates has improved functional results and promoted the development of "minimally invasive" surgical (MIS) approaches. Despite the availability of literature comparing between different types of osteosynthesis for KPPFF, there is a paucity of information available on the complications of osteosynthesis using locking plates, depending on the approach. We therefore carried out a retrospective multicenter study (nine centers: Dijon, Grenoble, Lille, Marseille, Nice, Paris, Saint-Étienne, Strasbourg, Colmar) as part of a Symposium of the French Society of Orthopedic Surgery and Traumatology (SOFCOT). Following osteosynthesis of KPPFF by locking plates carried out by a standard approach or by a minimally invasive approach (MIS), the objectives were: (1) to compare the complications, (2) to evaluate whether the radiological and clinical results (rate and time of consolidation, resumption of weight bearing, lack of reduction, postoperative autonomy) were comparable in the two groups.

HYPOTHESIS

The hypothesis was that performing an MIS approach in these indications does not confer more complications than a standard approach, and rather, the MIS approach offers better functional and radiological results.

MATERIAL AND METHOD

Five hundred and seventy-three patients presented with KPPFF over the periods studied (retrospective series from January 2012 to December 2016, then prospective series from January to December 2019). After applying the inclusion criteria (KPPFF by locking plate) and exclusion criteria (tumor context, infectious, intraoperative fractures, fractures on loose prostheses, other osteosynthesis methods, treatment by prosthetic revision, patients under the age of 18, follow-up less than 1-year, incomplete files), a global series of 306 patients was retained. Two groups were created according to the approach performed: a standard approach group (S, n=228) and a minimally invasive approach group (MIS, n=78). The demographic data of the population were recorded, as was the criteria for autonomy (Parker score, place of living). Postoperative complications were sought (infection, mechanical complication, surgical revision). Finally, the radiological and clinical results were evaluated (rate of, and time to consolidation, resumption of weight bearing, lack of reduction, postoperative autonomy).

RESULTS

The comparison of the two subgroups, S and MIS, found complication rates are comparable in the two groups in terms of infections [S group: n=18 (7.9%), MIS group: n=2 (2.6%)], mechanical complications [S: n=23 (10.1%), MIS: n=2 (2.6%)], and surgical revision [S: n=33 (14.5%), MIS: n=7 (8.9%)], and a lack of difference in postoperative autonomy [Parker; S group: 4.7±2.4 (0-9) vs. MIS group: 5±2, 7 (0-9)]. On the other hand, the time to return to weight bearing was shorter in the MIS group [4.3±3.5weeks (0-12) versus 10.1±10.1weeks (0-110), p<0.001]. The rate of nonunion was lower in the MIS group [n=1 vs. n=20, i.e. 1.7% vs. 11.1% (p=0.031)] and the time to consolidation was shorter [7.5±4.3weeks (6-30) versus 15.2±9.4weeks (5-78) (p<0.001)].

CONCLUSION

Performing an MIS approach in the management of KPPFF by locking plate osteosynthesis does not cause any more complications than a standard approach. In addition, higher consolidation rates can be obtained in shorter periods of time. This study suggests that it proposing osteosynthesis using the MIS approach as a primary surgery is a reasonable choice when treatment using locking plates is chosen for a KPPFF, subject to technical expertise.

LEVEL OF EVIDENCE

III; observational study.

Surgery Within 24 Hours Reduces Mortality and General Complication Rates in Patients Who Have Periprosthetic Femoral Fractures at the Hip

BACKGROUND

In patients who have hip fractures, treatment within 24 hours reduces mortality and complication rates. A similar relationship can be assumed for patients who have hip periprosthetic femoral fractures (PPFs) owing to the similar baseline characteristics of the patient populations. This monocentric retrospective study aimed to compare the complication and mortality rates in patients who had hip PPF treated within and after 24 hours.

METHODS

In total, 350 consecutive patients who had hip PPF in a maximum-care arthroplasty and trauma center between 2006 and 2020 were retrospectively evaluated. The cases were divided into 2 groups using a time to surgery (TTS) of 24 hours as the cutoff value. The primary outcome variables were operative and general complications as well as mortalities within 1 year.

RESULTS

Overall, the mean TTS was 1.4 days, and the 1-year mortality was 14.6%. The TTS ≤ 24 hours (n = 166) and TTS > 24 hours (n = 184) groups were comparable in terms of baseline characteristics and comorbidities. Surgical complications were equally frequent in the 2 groups (16.3 versus 15.2%, P = .883). General complications occurred significantly more often in the late patient care group (11.4 versus 28.3%, P < .001). In addition, the 30-day mortality (0.6 versus 5.5%, P = .012), and 1-year mortality (8.3 versus 20.5%, P = .003) rates significantly increased in patients who had TTS > 24 hours. Cox regression analysis yielded a hazard ratio of 4.385 (P < .001) for the TTS > 24 hours group.

CONCLUSIONS

Prompt treatment is required for patients who have hip PPF to reduce mortality and overall complications.

Comparative outcomes after treatment of peri-implant, periprosthetic, and interprosthetic femur fractures: which factors increase mortality risk?

Objectives

To compare mortality rates between patients treated surgically for periprosthetic fractures (PPF) after total hip arthroplasty (THA), total knee arthroplasty (TKA), peri-implant (PI), and interprosthetic (IP) fractures while identifying risk factors associated with mortality following PPF.

Design

Retrospective.

Setting

Single, Level II Trauma Center.

Patients/Participants

A retrospective review was conducted of 129 consecutive patients treated surgically for fractures around a pre-existing prosthesis or implant from 2013 to 2020. Patients were separated into 4 comparison groups: THA, TKA, PI, and IP fractures.

Intervention

Revision implant or arthroplasty, open reduction and internal fixation (ORIF), intramedullary nailing (IMN), percutaneous screws, or a combination of techniques.

Main Outcome Measurements

Primary outcome measures include mortality rates of different types of PPF, PI, and IP fractures at 1-month, 3-month, 6-month, 1-year, and 2-year postoperative. We analyzed risk factors associated with mortality aimed to determine whether treatment type affects mortality.

Results

One hundred twenty-nine patients were included for final analysis. Average follow-up was similar between all groups. The overall 1-year mortality rate was 1 month (5%), 3 months (12%), 6 months (13%), 1 year (15%), and 2 years (22%). There were no differences in mortality rates between each group at 30 days, 90 days, 6 months, 1 year, and 2 years (P-value = 0.86). A Kaplan-Meier survival curve demonstrated no difference in survivorship up to 2 years. Older than 65 years, history of hypothyroidism and dementia, and discharge to a skilled nursing facility (SNF) led to increased mortality. There was no survival benefit in treating patients with PPFs with either revision, ORIF, IMN, or a combination of techniques.

Conclusion

The overall mortality rates observed were 1 month (5%), 3 months (12%), 6 months (13%), 1 year (15%), and 2 years (22%), and no differences were found between each group at all follow-up time points. Patients aged 65 and older with a history of hypothyroidism and/or dementia discharged to an SNF are at increased risk for mortality. From a mortality perspective, surgeons should not hesitate to choose the surgical treatment they feel most comfortable performing.

Level of Evidence

Level III.

How Often Do Complications and Mortality Occur After Operatively Treated Periprosthetic Proximal and Distal Femoral Fractures? A Register-based Study

BACKGROUND

The incidence of periprosthetic femoral fractures is increasing because of an increasing number of primary THAs and TKAs. High rates of complications and mortality are associated with periprosthetic fractures, but few studies have evaluated and compared the population-based incidences of these events after fractures.

QUESTIONS/PURPOSES

(1) What is the annual incidence of periprosthetic fractures treated with surgery in one hospital district in Finland? (2) How are those incidences changing over time? (3) What is the risk of complications, reoperations, and death after those injuries?

METHODS

This register-based study evaluated 2259 patients who underwent revision THA or TKA or any surgery for a femoral fracture between January 2004 and December 2016 at the only hospital in our district where these types of operations are performed. During the study period, the diagnosis and operation codes of the operated-on patients varied greatly, and they were somewhat inaccurate. We thus evaluated radiographs of all 2259 patients one by one, and created inclusion and exclusion criteria based on radiologic findings and medical records. Of those, 12% (279 of 2259) had periprosthetic fractures that met the inclusion criteria, and from these, we formed two study groups (periprosthetic proximal femur fractures, n = 171; periprosthetic distal femur fractures, n = 108). Eighty-eight percent (1980 of 2259) of the patients were excluded because they were treated for a condition other than periprosthetic femoral fracture. The follow-up period ended in December 2019 or at the time the patient died. To evaluate the population-based incidence, we drew the number of individuals with THA or TKA in the hospital district from the Finnish Arthroplasty Register and the Finnish Hospital Discharge Register. The characteristics of patients with operatively treated periprosthetic femoral fractures were evaluated in terms of age, gender, fracture type, implant type, and time from the index operation to periprosthetic fracture. The annual incidences of periprosthetic femoral fractures are summarized per 1000 person-years of individuals living with an implanted THA or TKA and per 100,000 individuals per year living in our hospital district. The risks of death, complications, and reoperations were evaluated for both groups, and comparisons were made in terms of patient characteristics.

RESULTS

The mean annual incidence of operatively treated periprosthetic proximal femur fractures per 1000 people living with THA implants was 2.3 ± 0.9 (95% confidence interval 1.8 to 2.7) per year, and for those with periprosthetic distal femur fractures with TKA implants, it was 1.3 ± 0.6 (95% CI 1.0 to 1.7). There was an increasing trend in the incidence of periprosthetic proximal femur fractures from 1.6 to 3.8 (95% CI 1.8 to 2.8) per 1000 arthroplasties, and it increased from 0.4 to 1.7 (95% CI 2.4 to 4.4) for periprosthetic distal femur fractures between 2004 and 2016. The mean population-based incidence of periprosthetic proximal femur fractures per 100,000 person-years was 5.3 ± 2.2 (95% CI 4.1 to 6.4) per year, and for periprosthetic distal femur fractures, it was 3.4 ± 1.7 (95% CI 2.5 to 4.4). The incidence of periprosthetic proximal femur fractures related to 100,000 person-years increased from 3.2 to 8.9 (95% CI 3.9 to 6.6), while the incidence of periprosthetic distal femur fractures increased from 1.3 to 4.4 (95% CI 2.4 to 4.8) during the study period. The cumulative incidence of major complications after periprosthetic proximal femur fracture was 8.8% at 1 year (95% CI 5.1% to 13.6%) and 12.3% at 10 years (95% CI 7.5% to 18.4%), and after periprosthetic distal femur fracture, it was 7.4% at 1 year (95% CI 3.5% to 13.4%) and 9.3% at 10 years (95% CI 4.7% to 15.7%). The cumulative incidence of reoperation after periprosthetic proximal femur fracture was 10.5% at 1 year (95% CI 6.5% to 15.7%) and 13.5% at 10 years (95% CI 8.9% to 19.1%), and for periprosthetic distal femur fracture, it was 8.3% at 1 year (95% CI 4.1% to 14.5%) and 13.8% at 10% years (95% CI 7.8% to 21.4%). The cumulative incidence of death after periprosthetic proximal femur fracture was 8.2% at 1 year (95% CI 4.7% to 12.9%) and 47.3% at 10 years (95% CI 38.1% to 55.9%), and after periprosthetic distal femur fractures, it was 14.8% at 1 year (95% CI 8.8% to 22.2%) and 67.8% at 10 years (95% CI 56.3% to 76.9%).

CONCLUSION

The increased use of THA and TKA has led to an increase in the incidence of operatively treated periprosthetic fractures, which means there will be more revisions in the future. Older age, frailty of these patients, and often-complicated fracture patterns are related to a high rate of complications, reoperations, and mortality. Healthcare systems must prepare for a large increase in revisions for periprosthetic fracture, which are morbid events for patients and costly ones for healthcare systems.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Distal Femoral Replacement versus Operative Fixation for Periprosthetic Distal Femur Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

Open reduction and internal fixation (ORIF) and distal femoral replacement (DFR) have been utilized in the management of periprosthetic distal femur fractures. At present, much of the literature has been limited to small retrospective series. The purpose of the current investigation was to present the results of pooled data to determine the complication rates associated with ORIF and DFR.

METHODS

Publications from 2010 to 2020 describing 10 or more periprosthetic distal femur fractures treated with ORIF (ie, single plate, intramedullary nail, and dual fixation) or DFR were included, resulting in 32 publications and 1,258 fractures (977 ORIF and 281 DFR). Occurrence of surgical complications, reoperations, and medical complications were evaluated and compared.

RESULTS

The rate of surgical complications (ORIF versus DFR, 20.5 versus 14.9%, P = 1.0) and reoperations (12.9 versus 12.5%, P = 1.0) following DFR were similar. However, pooled analyses demonstrated that patients treated with DFR had a higher medical complication rate (ORIF versus DFR, 8.5 versus 23.1%, P = .0006).

CONCLUSION

ORIF and DFR for the treatment of periprosthetic distal femur fractures have similar surgical complication and reoperation profiles. While this review found an increased rate of medical complication following DFR, there are limitations in quality reporting in the literature, which should be considered when interpreting the study's findings. Failed ORIF can be salvaged with DFR, but the difficulty of this reoperation is dependent on the ORIF technique that was used. With future prospective studies, this review can help guide management of these fractures.

Short-term outcomes of periprosthetic compared to native distal femur fractures, a national database study

BACKGROUND

Distal femur fractures (DFFx) are highly morbid injuries with a complication rate comparable to hip fractures. Rising rates of total knee arthroplasty (TKA) have led to increasing rates of periprosthetic DFFx (pDFFx). We sought to determine how pDFFx complication rates differed from native DFFx (nDFFx).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients who sustained pDFFx or nDFFx between 2012 and 2018. Patients were further stratified by operative treatment: open reduction internal fixation (ORIF) or distal femur replacement (DFR). Multivariate logistic regression was used to compare 30-day complication rates between pDFFx versus nDFFx and, among pDFFx patients, ORIF versus DFR or revision TKA (rTKA).

RESULTS

563 patients with pDFFx and 2259 patients with nDFFx were identified between 2012 and 2018. pDFFx patients had significantly lower rates of ORIF than nDFFx patients (36.4 vs 95.4%, p < 0.001). On multivariate analysis, pDFFx were associated with a higher rate of surgical site complications (OR 2.48, p = 0.009) compared to nDFFx. There were no differences in mortality, reoperations, major complications, rate of blood transfusion, venous thromboembolism and disposition. In patients with pDFFx, patients undergoing DFR/rTKA were more likely to be discharged home versus a rehab facility, compared to those undergoing ORIF (OR 2.62, p < 0.001).

CONCLUSIONS

In this first large registry study comparing pDFFx and nDFFx, we find similar outcomes between these groups in the first 30 days after surgery. Patients with pDFFx did have higher rates of surgical site complications, including infection and dehiscence. In pDFFx patients, those undergoing DFR were more likely to return home post-operatively.

The influence of calcar collar and surface finish in the cemented femoral component on the incidence of postoperative periprosthetic femoral fracture at a minimum of five years after primary total hip arthroplasty

INTRODUCTION

Cemented femoral component design including its mechanical behavior in total hip arthroplasty (THA) has influenced the occurrence of postoperative periprosthetic femoral fracture (PPFF). The main aim of this study was to investigate the influence of the calcar collar and surface finish in the cemented femoral component on the risk of PPFF.

MATERIALS AND METHODS

This retrospective review was undertaken of 1082 primary THAs in 912 patients using cemented femoral components followed for a minimum of five years (mean, 9.4 years; range, 5-24 years). The incidence of PPFF, patients' demographics and surgical details were evaluated. Kaplan-Meier survivorship analysis was performed for four different outcomes: any PPFF, revision of the femoral component for PPFF, aseptic loosening, and for any reason.

RESULTS

The overall incidence of PPFFs was 1.0% (n = 11): 1.4% (n = 10) in the collarless polished (CLP) group, none in the collared polished (CP) group and 0.6% (n = 1) in the collared non-polished (CNP) group (p > 0.05). Kaplan-Meier survival analysis for the femoral component at 12 years with PPFF as the end point was 97.4% (95% confidence interval [CI], 94.9 to 99.8) in the collarless group and 99.7% (95% CI, 99.1 to 100) in the collared group (p = 0.048). With revision of the femoral component for aseptic loosening as the end point, survivorship was 100.0% in the CLP and CP groups, and 98.1% (95% CI, 95.9 to 100) in the CNP group (CLP vs CP, p > 0.999; CLP vs CNP, p = 0.001; CP vs CNP, p = 0.112).

CONCLUSION

This study demonstrated that the calcar collar in the cemented femoral component could play an important role to reduce the incidence of PPFF. The surface finish in the cemented femoral components influenced the incidence of femoral component revision for aseptic loosening over 5-12 years. Surgeons should consider not only the geometry and the mechanical function of the femoral components based on different design philosophies, but also potential complications associated with different designs that may require revision arthroplasty.

Distal Femur Replacement Versus Open Reduction and Internal Fixation for Treatment of Periprosthetic Distal Femur Fractures: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare complications and functional outcomes of treatment with primary distal femoral replacement (DFR) versus open reduction and internal fixation (ORIF).

DATA SOURCES

PubMed, Embase, and Cochrane databases were searched for English language studies up to May 19, 2020, identifying 913 studies.

STUDY SELECTION

Studies that assessed complications of periprosthetic distal femur fractures with primary DFR or ORIF were included. Studies with sample size ≤5, mean age <55, nontraumatic indications for DFR, ORIF with nonlocking plates, native distal femoral fractures, or revision surgeries were excluded. Selection adhered to the PRISMA criteria.

DATA EXTRACTION

Study quality was assessed using previously reported criteria. There were 40 Level IV studies, 17 Level III studies, and 1 Level II study.

DATA SYNTHESIS

Fifty-eight studies with 1484 patients were included in the meta-analysis. Complications assessed {incidence rate ratio [IRR] [95% confidence interval (CI)]: 0.78 [0.59-1.03]} and reoperation or revision [IRR (95% CI): 0.71 (0.49-1.04)] were similar between the DFR and ORIF cohorts. The mean knee range of motion was greater in the ORIF cohort (DFR: 90.47 vs. ORIF: 100.36, P < 0.05). The mean Knee Society Score (KSS) (DFR: 79.41 vs. ORIF: 82.07, P = 0.35) and return to preoperative ambulatory status were similar [IRR (95% CI): 0.82 (0.48-1.41)].

CONCLUSIONS

In comparing complications among patients treated for periprosthetic distal femur fracture with DFR or ORIF, there was no difference between the groups. There were also no differences in functional outcomes, although knee range of motion was greater in the ORIF group. This systematic review and meta-analysis highlights the need for future prospective trials evaluating the outcomes of these divergent treatment strategies.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Beyond Hip Fractures: Other Fragility Fractures' Associated Mortality, Functional and Economic Importance: A 2-year-Follow-up

Background

Hip fractures are well researched in orthogeriatric literature. Equivalent investigations for fragility-associated periprosthetic and periosteosynthetic femoral, ankle joint, pelvic ring, and rib fractures are still rare.

The purpose of this study was to evaluate mortality, functional outcome, and socioeconomic parameters associated to the upper-mentioned fragility fractures prospectively in a 2-year follow-up.

Methods

Over the course of a year, all periprosthetic and periosteosynthetic femoral fractures (PPFF), ankle joint fractures (AJ), pelvic ring fractures (PR), and rib fractures (RF), that were treated on a co-managed orthogeriatric ward, were assessed. Parker Mobility Score (PMS), Barthel Index (BI), place of residence, and care level were recorded. After 2 years, patients and/or relatives were contacted by mailed questionnaires or phone calls in order to calculate mortality and reevaluate the mentioned parameters.

Results

Follow-up rate was 77.7%, assessing 87 patients overall. The relative mortality risk was significantly increased for PR (2.9 (95% CI: 1.5–5.4)) and PPFF (3.5 (95% CI: 1.2–5.8)) but not for RF (1.5 (95% CI: 0.4–2.6)) and AJ (2.0 (95% CI: 0.0–4.0)). Every fracture group except AJ showed significantly higher BI on average at follow-up. PMS was, respectively, reduced on average for PR and RF insignificantly, but significantly for PPFF and AJ in comparison to pre-hospital values. 10.0–27.3% (each group) of patients had to leave their homes permanently; care levels were raised in 30.0–61.5% of cases.

Discussion

This investigation provides a perspective for further larger examinations. PR and PPFF correlate with significant increased mortality risk. Patients suffering from PPFF, PR, and RF were able to significantly recover in their activities of daily living. AJ and PPFF conclude in significant reduction of PMS after 2 years.

Conclusion

Any fragility fracture has its impact on mortality, function, and socioeconomic aspects and shall not be underestimated. Despite some fractures not being the most common, they are still present in daily practice.

Mortality, Risk Factors and Risk Assessment after Periprosthetic Femoral Fractures-A Retrospective Cohort Study

Periprosthetic femoral fracture (PFF) is a devastating complication. Here, the authors aimed to determine the influence of the timing of surgery as a risk factor for mortality and poor postoperative outcome in patients suffering from PFF. A retrospective descriptive analysis of patients treated for PFF between January 2010 and March 2018 was performed. In addition to patient and treatment characteristics, we assessed mortality rates and postoperative functional outcome by using the Harris Hip and WOMAC score. One-year mortality after PFF was 10.7%. Delayed surgery after 48 h did not negatively influence mortality after PFF. The postoperative hospital stay did not influence the mortality rate, nor did it correlate with medical scores of comorbidities, general health or functionalities. Cementation of stem correlated negatively with the WOMAC score. Deceased patients had a higher Charlson Comorbidity Index (CCI) score, while American society of Anaesthesiologists (ASA) scores did not show a significant difference. There were no differences between ORIF and revision arthroplasty. In conclusion, delayed surgery after 48 h does not negatively influence mortality after PFF. The CCI seems to be a suitable tool to assess patients’ risk for increased mortality after PFF, while the usually used ASA score is not able to achieve a relevant risk assessment.

Retrospective Population-Based Cohort Study of Incidence, Complications, and Survival of 202 Operatively Treated Periprosthetic Femoral Fractures

BACKGROUND

The aim of this study is to investigate the population and primary total hip arthroplasty (THA)-based incidences, fracture types, complications, and survival of operatively treated periprosthetic femoral fracture (PFF).

METHODS

This retrospective study reviewed 202 cases of operatively treated PFFs in a study period from January 2004 to December 2016. The Vancouver classification was used to classify PFFs.

RESULTS

The incidence of PFF related to 1000 primary THAs per year was 2.7 (standard deviation 1.0, range 0.9-4.5) at a defined hospital district area during the study period. The mean population-based incidence of operatively treated PFFs raised from 1.6 to 4.5 per 100,000 person-years during the study period. The B1-type fracture was the most common fracture type in 71 of 202 (35%) of these PFFs. The cumulative incidence of re-revision was 10.9% at 1 year and 15.6% at 15 years (95% confidence interval [CI] 10.9-21.0). The cumulative incidence for other major complications was 6.4% at 1 year and 9.9% at 15 years (95% CI 5.9-15.0). The cumulative incidence of death after PFF was 7.4% at 1 year and 56.3% at 15 years (95% CI 41.3-68.8) during the follow-up time from January 1, 2004 to December 31, 2019.

CONCLUSION

This country-specific study showed a 3-fold increasing trend in the incidence of operatively treated PFFs from 2004 to 2016 per 1000 THAs. The Vancouver type B1 fracture was the most common type. A high number of complications were associated with PFFs and 7.4% of the patients had died within 1 year after PFF surgery.

Early Surgery Does Not Improve Outcomes for Patients with Periprosthetic Femoral Fractures-Results from the Registry for Geriatric Trauma of the German Trauma Society

Background and Objectives: Appropriate timing of surgery for periprosthetic femoral fractures (PFFs) in geriatric patients remains unclear. Data from a large international geriatric trauma register were analyzed to examine the outcome of patients with PFF with respect to the timing of surgical stabilization. Materials and Methods: The Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie (DGU)) (ATR-DGU) was analyzed. Patients treated surgically for PFF were included in this analysis. As outcome parameters, in-house mortality rate and mortality at the 120-day follow-up as well as mobility, the EQ5D index score and reoperation rate were analyzed in relation to early (<48 h) or delayed (≥48 h) surgical stabilization. Results: A total of 1178 datasets met the inclusion criteria; 665 fractures were treated with osteosynthesis (56.4%), and 513 fractures were treated by implant change (43.5%). In contrast to the osteosynthesis group, the group with implant changes underwent delayed surgical treatment more often. Multivariate logistic regression analysis of mortality rate (p = 0.310), walking ability (p = 0.239) and EQ5D index after seven days (p = 0.812) revealed no significant differences between early (<48 h) and delayed (≥48 h) surgical stabilization. These items remained insignificant at the follow-up as well. However, the odds of requiring a reoperation within 120 days were significantly higher for delayed surgical treatment (OR: 1.86; p = 0.003). Conclusions: Early surgical treatment did not lead to decreased mortality rates in the acute phase or in the midterm. Except for the rate of reoperation, all other outcome parameters remained unaffected. Nevertheless, for most patients, early surgical treatment should be the goal, so as to achieve early mobilization and avoid secondary nonsurgical complications. If early stabilization is not possible, it can be assumed that orthogeriatric co-management will help protect these patients from further harm.

Management of low periprosthetic distal femoral fractures

AIMS

Debate continues regarding the optimum management of periprosthetic distal femoral fractures (PDFFs). This study aims to determine which operative treatment is associated with the lowest perioperative morbidity and mortality when treating low (Su type II and III) PDFFs comparing lateral locking plate fixation (LLP-ORIF) or distal femoral arthroplasty (DFA).

METHODS

This was a retrospective cohort study of 60 consecutive unilateral (PDFFs) of Su types II (40/60) and III (20/60) in patients aged ≥ 60 years: 33 underwent LLP-ORIF (mean age 81.3 years (SD 10.5), BMI 26.7 (SD 5.5); 29/33 female); and 27 underwent DFA (mean age 78.8 years (SD 8.3); BMI 26.7 (SD 6.6); 19/27 female). The primary outcome measure was reoperation. Secondary outcomes included perioperative complications, calculated blood loss, transfusion requirements, functional mobility status, length of acute hospital stay, discharge destination and mortality. Kaplan-Meier survival analysis was performed. Cox multivariate regression analysis was performed to identify risk factors for reoperation after LLP-ORIF.

RESULTS

Follow-up was at mean 3.8 years (1.0 to 10.4). One-year mortality was 13% (8/60). Reoperation was more common following LLP-ORIF: 7/33 versus 0/27 (p = 0.008). Five-year survival for reoperation was significantly better following DFA; 100% compared to 70.8% (95% confidence interval (CI) 51.8% to 89.8%, p = 0.006). There was no difference for the endpoint mechanical failure (including radiological loosening); ORIF 74.5% (56.3 to 92.7), and DFA 78.2% (52.3 to 100, p = 0.182). Reoperation following LLP-ORIF was independently associated with medial comminution; hazard ratio (HR) 10.7 (1.45 to 79.5, p = 0.020). Anatomical reduction was protective against reoperation; HR 0.11 (0.013 to 0.96, p = 0.046). When inadequately fixed fractures were excluded, there was no difference in five-year survival for either reoperation (p = 0.156) or mechanical failure (p = 0.453).

CONCLUSION

Absolute reoperation rates are higher following LLP fixation of low PDFFs compared to DFA. Where LLP-ORIF was well performed with augmentation of medial comminution, there was no difference in survival compared to DFA. Though necessary in very low fractures, DFA should be used with caution in patients with greater life expectancies due to the risk of longer term aseptic loosening. Cite this article: Bone Joint J 2021;103-B(4):635-643.

Does early surgery improve outcomes for periprosthetic fractures of the hip and knee? A systematic review and meta-analysis

INTRODUCTION

Previous evidence has established that early surgery is beneficial to improve outcomes for individuals with native hip fractures in the elderly population. Patients who sustain a periprosthetic fracture have been demonstrated to have similar demographics and outcomes as those with native fractures around the hip and knee. We therefore set out to determine if there is a similar difference in perioperative outcomes between early and delayed surgery for periprosthetic fractures of the hip and knee through a systematic review and meta-analysis.

METHODS

Literature search outputs were screened for studies meeting the inclusion criteria. The groups of early surgery and delayed surgery were defined by study authors. The primary outcome measure was 30 day mortality. Where there was sufficient study homogeneity, a random-effects meta-analysis was performed. Individual study risk of bias was assessed using the ROBINS-I criteria, with the GRADE criteria used for independent outcome evaluation. The review protocol was registered on PROSPERO prior to commencement (Registration number CRD42019149360).

RESULTS

The inclusion criteria was met in 11 studies (n = 3006). Mean time to surgery from admission for reporting studies was 64 h. 59.6% patients underwent early surgery as defined by the study authors. We identified a significantly lower risk of 30 day mortality for those with early surgery versus delayed surgery (RR 0.21; 95% CI 0.05, 0.90; p = 0.04, n = 2022). There were also significantly better outcomes for early versus delayed surgery regarding: medical complications, length of stay, transfusion risk, and reoperation. The quality of evidence for all the individual outcomes was low or very low.

CONCLUSIONS

There is evidence that delaying surgery in those with periprosthetic fractures of the hip and knee has a deleterious impact on mortality and other important patient outcomes. There are, however, notable limitations to the existing available literature, with further appropriately designed large-scale studies required to confirm these findings.

[Locking plate fixation of distal periprosthetic femoral fractures : Clinical outcome and mortality]

Hintergrund

Die Versorgung distaler periprothetischer Femurfrakturen (PFF) stellt aufgrund des geriatrischen Patientenkollektivs eine große interdisziplinäre Herausforderung dar und erfolgt (abhängig vom Frakturtyp) häufig mittels winkelstabiler Plattenosteosynthese (WPO), wobei bisher nur wenige Daten zum klinischen Outcome existieren. Ziel der Untersuchung ist die Identifikation von Risikofaktoren für ein schlechtes Outcome und erhöhte Mortalität.

Methoden

In dieser retrospektiven Studie wurden 36 Fälle mit distaler PFF untersucht. Eingeschlossen wurden nur Versorgungen mit WPO. Neben relevanten Vorerkrankungen (ASA-Score, Charlson Index), der Frakturmorphologie und relevante Komplikationen, wurden u.a. die 1- und 3-Jahres-Mortalität, sowie das klinische Outcome mit Hilfe des Lysholm-Scores erfasst.

Ergebnisse

Die 1- und 3- Jahres Mortalität betrug 9% bzw. 26%, wobei dies ausschließlich ASA 3 und 4 Patienten betraf. Der Lysholm Score zeigte eine hohe Variabilität (65 ± 27 Punkte) mit höheren Werten in der ASA 1-2 Subgruppe (82 vs. 63 Punkte) aber unabhängig vom Frakturtyp. Als Risikofaktoren für die 3-Jahres Mortalität konnten der präoperative ASA-Score, der Charlson Komorbiditätsindex und das Patientenalter identifiziert werden.

Diskussion

Die dargestellte Fallserie weist eine hohe absolute Mortalitätsrate auf, auch wenn diese im Vergleich zu bisher publizierten Daten, etwas geringer war. Die Rate an Sekundärdislokationen, fehlender Frakturheilung oder Folgeoperationen war ebenfalls gering. Die WPO erscheint daher als geeignete Versorgung für Frakturen mit stabiler Prothese. Jedoch besteht eine hohe Variabilität im klinischen Outcome unabhängig vom Frakturtyp, sowie signifikant erhöhte Mortalitätsraten bei vorerkrankten Patienten.

Demographics, Treatment, and Cost of Periprosthetic Femur Fractures: Fixation Versus Revision

Introduction:

Periprosthetic femur fractures (PPFX) are complications of both total hip and knee arthroplasty and may be treated with open reduction and internal fixation (ORIF) or revision arthroplasty. Differences in treatment and fracture location may be related to patient demographics and lead to differences in cost. Our study examined the effects of demographics and treatment of knee and hip PPFXs on length of stay (LOS) and cost.

Methods:

Of all, 932 patients were identified with hip or knee PPFXs in the National Inpatient Sample from January 2013 to September 2015. Age, gender, race, mortality, comorbidity level, LOS, total cost, procedure type, geographic region, and hospital type were recorded. A generalized linear regression model was conducted to analyze the effect of fracture type on LOS and cost.

Results:

Differences in gender (66% vs 83.7% female, P < .01), comorbidities (fewer in hips, P < .01), and costs (US$30 979 vs US$27 944, P < .01) were found between the hip and knee groups. Knees had significantly higher rates of ORIF treatment (80.7% vs 39.1%) and lower rates of revision arthroplasties (19.3% vs 60.9%) than hip PPFXs (P < .01). Within both groups, patients with more comorbidities, revision surgery, and blood transfusions were more likely to have a longer LOS and higher cost.

Conclusion:

Periprosthetic femur fractures patients are not homogenous and treatment varies between hip and knee locations. For knee patients, those treated with ORIF were younger, with fewer comorbidities than those treated with revision. Conversely, hip patients treated with ORIF were older, with more comorbidities than those treated with revision. Hips had higher costs than knees, and cost correlated with revision arthroplasty and more comorbidities. In both hip and knee groups, longer LOS was associated with more comorbidities and being treated in urban teaching hospitals. Total cost had the strongest associations with revision procedures as well as number of comorbidities and blood product use.

Incidence, Classification, and Risk Factors for Intraoperative Periprosthetic Femoral Fractures in Patients Undergoing Total Hip Arthroplasty With a Single Stem: A Retrospective Study

BACKGROUND

The collum femoris preserving (CFP) stem was a specially designed femoral neck preserving component. The incidence, classification, and risk factors for intraoperative periprosthetic femoral fractures with this special stem remain unclear.

METHODS

This was a retrospective study. We analyzed the clinical and radiological data of all patients who underwent primary hip arthroplasty with a CFP stem in our hospital between January 2006 and November 2018. Demographic characteristics and radiological features were obtained from the medical records and the Picture Archiving and Communication System, respectively. The incidence, Vancouver classification, and risk factors for intraoperative periprosthetic femoral fractures were identified.

RESULTS

A total of 1633 hips were included. The incidence rate of periprosthetic femoral fractures in patients undergoing total hip arthroplasty with a CFP stem was 3.2%. According to the Vancouver classification, there were 24 patients (45.3%) with Vancouver type A fractures, 27 patients (50.9%) with Vancouver type B fractures, and 2 patients (3.8%) with Vancouver type C fractures. Five independent risk (protective) factors were found, including surgical history (odds ratio [OR] = 3.275, 95% confidence interval [CI] = 1.192-8.997), neck-shaft angle (OR = 1.104, 95% CI = 1.058-1.152), neck length preserved (OR = 0.913, 95% CI = 0.850-0.980), canal flare index (OR = 0.636, 95% CI = 0.413-0.980), and bone mineral density (OR = 0.083, 95% CI = 0.016-0.417).

CONCLUSION

The detailed characteristics of intraoperative periprosthetic femoral fractures in patients who received a CFP stem were identified in this study. Cracks of the femoral neck and fractures on the front side of the proximal femur were more common in patients with CFP stems. As a kind of a femoral neck preserving stem, the anatomical features (eg, neck-shaft angle, preserving length) of the remaining femoral neck might influence the incidence and characteristics of intraoperative periprosthetic femoral fractures in patients with CFP stems.