Undetected Intraoperative Periprosthetic Femoral Fractures in Patients Undergoing Primary Total Hip Arthroplasty: A Retrospective Case Series and Literature Review

Impact of Intraoperative Femoral Fractures During Cemented Hemiarthroplasty for Femoral Neck Fractures

BACKGROUND

There have been several studies on intraoperative femoral fractures (IFFs) during primary total hip arthroplasty, but it is not well understood how this complication affects the patient population undergoing cemented hemiarthroplasty. This study aimed to analyze the impact of IFFs sustained during cemented hemiarthroplasty for the treatment of femoral neck fractures.

METHODS

A retrospective review was conducted of all patients who were treated for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association 31B fractures with cemented hemiarthroplasty between January 1, 2000 and December 31, 2021, at a single academic level 1 trauma center. An initial cohort was constructed of all patients who sustained an IFF during their surgery, yielding 31 patients after excluding those who sustained a pathologic fracture or had incomplete data. These patients were matched 1:2 on age, sex, and body mass index to patients in a control cohort. The primary outcome measure was implant failure. Secondary outcome measures included complications, all-cause mortality, and radiographic outcomes (subsidence, femoral component loosening, acetabular wear, and heterotopic ossification) postoperatively.

RESULTS

Subsequent implant revision was required in 3.2% (n = 1) of patients who sustained an IFF and 1.6% (n = 1) of patients who did not. After adjusting for comorbidities, there was no observed excess risk of implant failure in the fracture cohort when compared to the control cohort (hazard ratio [HR] = 0.30, P = 0.740). There was no observed excess risk of morbidity (HR = 0.69, P = 0.621) or all-cause mortality (HR = 0.23, P = 0.330). Radiographic outcomes also did not significantly differ between the 2 cohorts (P > 0.05).

CONCLUSIONS

Intraoperative fractures during cemented hemiarthroplasty do not contribute to an increased risk of secondary surgery, morbidity, or mortality after surgery. They also do not adversely affect radiographic outcomes postoperatively.

LEVEL OF EVIDENCE

Level III, Retrospective Comparative Study.

Intraoperative Femoral Fractures During Primary Total Hip Arthroplasty Are Associated With Increased Revision and Complication Rates

BACKGROUND

Intraoperative femoral fractures are a rare, but serious complication of primary total hip arthroplasty (THA), and little is known about the rates of complications and reoperations in these patients. The objective of this investigation was to describe the two-year outcomes and revision rates in patients who sustain an intraoperative femoral fracture during THA.

METHODS

A large administrative claims database was queried for patients who sustained an intraoperative femoral fracture during primary and elective THA from 2015 to 2022. Patients requiring THA for tumors or fractures were excluded. Patients who sustained an intraoperative fracture were matched 1:1 based on age, sex, and comorbidity burden. The incidence of medical and surgical complications was compared between cohorts. Kaplan-Meier and multivariate analyses were used to compare two-year outcomes between groups.

RESULTS

Among matched cohorts of 2,795 patients, those who sustained an intraoperative femoral fracture experienced higher rates of periprosthetic joint infection (PJI) (odds ratio [OR]: 2.0, P < 0.001), instability (OR: 1.6, P = 0.013), revision THA (OR: 2.7, P < 0.001), deep vein thrombosis (OR: 3.0, P < 0.001), and transfusion (OR: 2.8, P < 0.001) at 90 days and demonstrated significantly longer length of stay (5.7 ± 6.3 versus 3.6 ± 4.5 days, P < 0.001). At a 2-year follow-up, patients who had an intraoperative femoral fracture were more likely to develop a PJI (OR: 2.1, P < 0.001), periprosthetic fracture (OR: 1.6, P = 0.030), aseptic loosening (OR: 3.0, P < 0.001), and instability (OR: 1.7, P = 0.001) and undergo all-cause revision (OR: 2.3, P < 0.001).

CONCLUSIONS

Patients who sustained an intraoperative femoral fracture during primary THA were significantly more likely to develop PJI, periprosthetic fracture, aseptic loosening, instability, undergo revision THA, and experience medical complications. Strategies to mitigate intraoperative fracture during THA are necessary to improve outcomes in these high-risk patients.

What is the clinical utility of acoustic and vibrational analyses in uncemented total hip arthroplasty?

BACKGROUND

Despite recent developments in THA, a more objective method is needed to assist orthopedic surgeons in identifying the insertion endpoint of the broaching procedure. Therefore, this systematic review evaluated the in-vivo efficacy of various acoustic and vibration analyses in detecting proper implant seating, identifying intraoperative complications, and quantifying the accuracy of predictive modeling using acoustics.

METHODS

Four electronic databases were searched on July 23rd, 2023, to retrieve articles evaluating the use of acoustic analysis during THA. The search identified 835 unique articles, which were subsequently screened by two independent reviewers as per our inclusion and exclusion criteria. In total, 12 studies evaluating 580 THAs were found to satisfy our criteria and were included in this review.

RESULTS

Methodologically, analyses have suggested stopping broaching when consecutive blows emit similar acoustic profiles (maximum peak frequency ± 0.5 kHz), which indicates proper implant seating in terms of stability and mitigates subsidence. Also, abrupt large deviations from the typical progression of acoustic signals while broaching are indicative of an intraoperative fracture. Since height, weight, femoral morphological parameters, and implant type have been shown to alter acoustic emissions while hammering, incorporating these factors into models to predict subsidence or intraoperative fracture yielded virtually 100% accuracy in identifying these adverse events.

CONCLUSION

These findings support that acoustic analyses during THA show promise as an accurate, objective, and non-invasive method to predict and detect proper implant fixation as well as to identify intraoperative fractures.

TRIAL REGISTRATION

PROSPERO registration of the study protocol: CRD42023447889, 23 July 2023.

Intraoperative Periprosthetic Fractures in Total Hip Arthroplasty: A 1.6-Million-Patient Analysis of Complications, Costs, and the Challenges in AI-Based Prediction

Background: Periprosthetic fractures following total hip arthroplasty are serious complications occurring in up to 2.4% of primary cases, contributing to significant morbidity, extended hospital stays, and elevated healthcare costs. Predicting these fractures remains a challenge despite advances in surgical techniques and prosthetic materials. Methods: This study analyzed 1,634,615 cases of primary THA from the NIS database (2016-2019) using propensity score matching to compare outcomes between patients with and without intraoperative periprosthetic fractures. Predictive models, including logistic regression, decision tree, and deep neural network, were evaluated for their ability to predict fracture risk. Results: Patients with periprosthetic fractures exhibited a 14-fold increase in pulmonary embolism risk, a 12-fold increase in infections, and a 5-fold increase in hip dislocations. Fractures extended hospital stays (3.8 vs. 2.5 days) and added approximately USD 32,000 in costs per patient. The predictive models yielded low accuracy (AUC max = 0.605), underscoring the complexity of predicting periprosthetic fractures. Conclusions: Intraoperative periprosthetic fractures in THA significantly elevate complication rates, costs, and length of stay. Despite extensive modeling efforts, accurate prediction remains difficult, highlighting the need to focus on preventive strategies, such as improved surgical techniques and real-time intraoperative monitoring.

Long-term survival and complication rate of cementless prosthetic stems in primary total hip arthroplasty categorized by types according to Mont classification: a regional registry-based study on 53,626 implants

INTRODUCTION

The purpose of this retrospective registry-based study is to assess survival and causes of failure of cementless stem implants used in total hip arthroplasty (THAs), to ascertain if there are differences when these are categorized according to the six types described by Mont.

METHODS

Data collected from the regional registry regarding all primary THAs performed from 2000 to 2019 were analyzed. Femoral prosthetic stems were divided into the six types of Mont classification. For each stem type, number of implants, survival and causes of failure were evaluated and compared.

RESULTS

The most frequently implanted stem type was the 3c type (53.4%). Type 1 had the lowest stem failure rate (1.6%), and type 6 showed the highest (3.9%). Periprosthetic fracture was the most frequent complication in type 6, accounting for 34.5% of failures. Aseptic loosening was the main complication in type 2 stems, accounting for 36.4% of failures. Pairwise comparisons showed significant higher survival of type 1 compared to type 3c (p = 0.000026) and type 6 (p = 0.000076), and between type 3a compared to type 3c (p = 0.03) and type 6 (p = 0.026).

CONCLUSION

Significant variations in implant survival rates were found among the six Mont-types of cementless stems. These findings emphasize the paramount importance of stem design and fixation area in determining long-term survival, providing a guidance for orthopedic surgeons in the selection of the most appropriate stem for primary THA, contributing to our understanding of cementless stem performance, presenting invaluable insights to further improve patient outcomes in THA surgery.

Exploring Individualized Approaches to Managing Vancouver B Periprosthetic Femoral Fractures: Insights from a Comprehensive Case Series Analysis

The increasing prevalence of periprosthetic femoral fractures, specifically in the vicinity of the hip, has emerged as a significant issue in recent times. Consequently, there is a need for a thorough examination to enhance the effectiveness of management and treatment approaches. The findings of this study emphasize a significant disparity in the occurrence and characteristics of these fractures, and the multiple cases have highlighted the efficacy of various treatment strategies, such as open reduction and internal fixation, as well as the utilization of cortical strut allografts. Furthermore, the study has identified potential risk factors that have an impact on the characteristics of fractures, providing valuable insights that could be crucial in the development of preventive strategies. This study provides a thorough examination of periprosthetic femoral fractures, highlighting the importance of a cohesive treatment algorithm to improve the handling of such fractures. Moreover, it promotes the need for a collaborative endeavor in conducting research in this field, cultivating a more profound comprehension that has the potential to drive progress in therapeutic approaches, ultimately enhancing patient results over an extended period of time. It is crucial that forthcoming research endeavors persist in expanding upon these discoveries, striving towards a unified methodology in tackling this substantial clinical obstacle.