Uncemented total hip arthroplasty; increased risk of early periprosthetic fracture requiring revision surgery in elderly females

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.

Temporal Patterns and Treatment Associations in Complications Following Hip Arthroplasty

Background and Objectives: Hip arthroplasty is commonly performed to enhance mobility and quality of life in patients with severe joint degeneration. However, post-surgery complications such as infections, dislocations, and mechanical failures remain prevalent and vary over time. This study examines the relationship between time intervals post-surgery and the occurrence of complications and explores the associations between specific treatment modalities and complications. It also investigates temporal patterns of infectious and mechanical complications to inform more effective post-surgery care. Materials and Methods: A retrospective cohort study was conducted on hip arthroplasty patients to analyze the occurrence and distribution of complications across medium-term (1-5 years) and long-term (≥6 years) intervals. Treatment modalities, including joint debridement, lavage, antibiotics, and mechanical interventions, were analyzed for their association with complications. Chi-Square tests were used, with significance set at p < 0.05. Results: A significant association was found between time intervals and complications (χ2 = 58.149, df = 19, p < 0.001). Infections were more prevalent in the medium-term, while mechanical complications such as dislocation, implant loosening, and periprosthetic fractures were more common in the long-term. Antibiotics were strongly linked to infectious complications (χ2 = 279.000, p < 0.001), and mechanical treatments were associated with fractures and dislocations. Conclusions: The study confirms that the timing of complications post-surgery plays a critical role in their occurrence. Specific complications become more prevalent at different intervals, emphasizing the need for tailored treatment strategies. Antibiotics for infections and mechanical interventions for fractures and dislocations should be adjusted based on timing. These findings highlight the importance of time-specific post-surgery care and suggest areas for further research on long-term strategies and risk factors.

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.

Variation in Demographics, Hospital, and Patient-Reported Outcomes Following Total Hip Arthroplasty According to Biological Sex

BACKGROUND

The effect of biological sex on the outcomes of total hip arthroplasty (THA) remains unclear. Accounting for biological sex in research is crucial for reproducibility and accuracy. Average combined data may mask sex-related variation and obscure clinically relevant differences in outcomes. The aim of this study is to investigate hospital and patient-reported outcome measures (PROMs) after THA by biological sex to elucidate differences and ultimately provide more equitable care.

METHODS

We performed a retrospective review of patients undergoing primary THA at a single large academic center between January 2013 and August 2020. Demographics, operative variables, hospital outcomes, and PROMs were compared between men and women patients. The PROMs included preoperative, 6-weeks, 6-months, and 1-year Single Assessment Numeric Evaluation, Visual Analog Scale, Hip Disability and Osteoarthritis Outcome Score Joint Replacement, University of California, Los Angeles, and Patient-Reported Outcomes Measurement Information System mental and physical scores, as well as satisfaction scores.

RESULTS

A total of 6,418 patients were included (55% women). Women were older (P < .001), had a lower body mass index (P < .001), and were more likely to have public insurance (P < .001). Fewer women were discharged to home or self-care (P < .001). Women had higher rates of cementation (P < .001) and fracture within 90 days (P < .001), and these associations remained significant with adjusted multivariable analyses. Women had significantly higher pain and lower functional scores preoperatively; postoperatively, most PROMs were equivalent.

CONCLUSIONS

Important differences were observed in several areas. Demographic parameters differed, and a variable effect of biological sex was observed on surgical and hospital outcomes. Women had an increased incidence of cemented femoral components (indicated for osteoporotic bone) and postoperative fractures. Women's PROMs demonstrated globally lower functional scores and higher pain preoperatively. Differences attributed to sex should continue to be investigated and accounted for in risk-stratification models. Future studies are needed to elucidate the underlying causes of observed biological sex differences and are essential for equitable arthroplasty care.

[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.

Risk of peri‑implant femoral fracture after cephalomedullary nailing in older patients with trochanteric fractures

INTRODUCTION

Despite the recent increase in the use of cephalomedullary nails for trochanteric hip fractures, factors that may be associated with peri‑implant femoral fracture (PIFF) after cephalomedullary nailing for trochanteric fractures remain unknown. We investigated the factors associated with PIFF after cephalomedullary nailing of trochanteric hip fractures in older patients.

METHODS

A nested case-control study was conducted using a database of patients aged ≥65 years who underwent surgery with cephalomedullary nails for trochanteric fractures caused by low-energy trauma during 2005-2021. The cases were defined as patients who developed PIFF after surgery, while controls were patients who did not develop PIFF and who were followed up for ≥3 years after surgery. Four controls were randomly matched to each case for sex and age. First, potential factors associated with PIFF were compared between cases and controls. Second, multivariable conditional logistic regression analysis was employed to assess factors possibly associated with PIFF, controlling for potential confounding factors.

RESULTS

Of 1531 patients who underwent surgery with cephalomedullary nails because of trochanteric fractures, we assessed 34 cases and 136 controls (N = 170; mean age 85.7 ± 7 years; and females, 94 %). PIFF was significantly associated with patients having undergone total knee arthroplasty (adjusted odds ratios [95 % confidence intervals], 4.41 [1.16-16.8]) and those with AO/OTA classification 31A3 fracture (A3 fracture) (2.3 [1.12-4.76]), after adjusting for potential confounding factors.

CONCLUSIONS

Our results showed that PIFF was more likely to develop among older patients with a clinical history of total knee arthroplasty and A3 fracture. These findings suggest that such patients may require careful follow-up with rigorous assessments after cephalomedullary nailing for trochanteric fractures.

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.

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

BACKGROUND

The American Academy of Orthopaedic Surgeons guidelines report moderate evidence for cementing femoral stems for hip fractures, mainly derived from hemiarthroplasty literature. This is the first large, nonregistry study examining the influence of femoral fixation, implant type, patient characteristics, and radiographic factors on outcomes after total hip arthroplasty (THA) for acute femoral neck fractures.

METHODS

A multicenter retrospective study was performed of 709 THA cases (199 cemented, 510 cementless) for femoral neck fractures from 2006 to 2020 at three large academic institutions. Demographics, perioperative characteristics, and radiographs were reviewed. Kaplan-Meier survivorship curves were generated for multiple outcomes. Univariate and multivariate analyses were performed with P ≤ .05 denoting significance.

RESULTS

Cementless stems had a higher all-cause aseptic femoral revision rate (5.1 versus 0.5%, P = .002) and periprosthetic femoral fracture rate (4.3 versus 0%, P = .001). Each successive Dorr type had a higher fracture rate with cementless implants: 2.3%, 3.7%, and 15.9% in Dorr A, B, and C, respectively (P < .001). Logistic regression analyses confirmed that cementless stems (P = .02) and Dorr C bone (P = .001) are associated with periprosthetic fractures; collared implants and prophylactic cables did not protect against fractures. There was no difference in rates of dislocation, septic revision, or mortality between groups.

CONCLUSION

Cementless stems during THA for femoral neck fractures have a higher aseptic femoral revision rate, specifically for periprosthetic fractures. Dorr C bone was particularly prone with an alarmingly high fracture rate. All fractures occurred in cementless cases, suggesting that cemented stems may minimize this complication.

LEVEL OF EVIDENCE

III.