A multicentre comparative analysis of fixation versus revision surgery for periprosthetic femoral fractures following total hip arthroplasty with a cemented polished taper-slip femoral component

Risk factors influencing periprosthetic fracture and mortality following total hip arthroplasty with a cemented, collarless, polished taper femoral component : a minimum ten-year follow-up cohort study

Aims

The aims of this study were to evaluate the incidence of reoperation (all-cause and specifically for periprosthetic femoral fracture (PFF)) and mortality, and associated risk factors, following total hip arthroplasty (THA) incorporating a cemented collarless polished taper slip (PTS) femoral component.

Methods

This study included a consecutive series of THAs performed with an Exeter PTS between January 2011 and December 2013 at a single centre. Patient demographics, diabetes, American Society of Anesthesiologists (ASA) grade, and admission type were collected. Co-primary outcomes were reoperation and death.

Results

The cohort consisted of 2,177 patients (mean age 66.9 years (SD 11.8)). The median follow-up was 11 years (IQR 10.5 to 11.8). The indications for reoperation were PFF (n = 35, 1.6%), dislocation (n = 15, 0.7%), aseptic cup loosening (n = 13, 0.6%), and infection (n = 10, 0.5%). No femoral components were revised for aseptic loosening. The ten-year aseptic survival for the femoral components was 96.5% (95% CI 95.3 to 97.7). ASA grade III to IV was associated with a higher risk of both all-cause reoperation (hazard ratio (HR) 1.86, p = 0.017) and aseptic reoperation (HR 1.82, p = 0.031). The ten-year PFF-related femoral component survival was 97.7% (95% CI 96.9 to 98.5) and older age (HR 1.05, p = 0.004) and diabetes (HR 2.32, p = 0.048) were independently associated with the occurrence of PFF. Overall patient survival at ten years was 66.1% (95% CI 63.4 to 68.8), with male sex (HR 1.23, p = 0.010), older age (HR 1.08, p < 0.001), ASA grade II to IV (HR 2.22, 4.14 and 6.74, respectively, p ≤ 0.001), and THA undertaken for trauma (HR 1.79, p < 0.001) being independently associated with an increased mortality risk.

Conclusion

The cemented PTS demonstrated excellent long-term survival in THA, but PFF was the most common reason for reoperation. Older age and diabetes were independently associated with PFFs. Higher ASA grade was linked to increased risk of both all-cause and aseptic reoperations. Mortality at ten years was influenced by male sex, older age, higher ASA grade, and trauma-related THA.

Reduced periprosthetic fracture rate for a cemented anatomical versus a tapered polished stem in hip arthroplasty: A 6-year follow-up of a prospective observational cohort study

Purpose

In older patients requiring a hip arthroplasty, the cemented straight collarless polished tapered stems (PTSs) have been linked to an increased risk of periprosthetic femur fractures (PFFs) when compared to anatomically shaped stems (ASs). This study aims to perform a 6-year follow-up of PFF rates and other adverse events of an orthopaedic department's full transition from a cemented PTS to a cemented AS.

Methods

A prospective single-centre cohort study included 1077 patients operated with a cemented hip replacement at Danderyd Hospital, Stockholm, Sweden, between 2012 and 2015. Patients were divided into two groups based on stem design: PTS (n = 543) and AS (n = 534). Outcomes included the PFF rate, periprosthetic joint infection (PJI) and prosthetic dislocation. A Cox proportional hazards model was used to estimate outcomes.

Results

Most patients (77.2%, mean age 82 years) underwent surgery for a hip fracture. The 6-year PFF rate was 4.6% for the PTS group and 0.9% for the AS group. PFF patterns differed between groups, with Vancouver B fractures being more common in the PTS group. The AS group had lower rates of PJIs (3.6% vs. 1.7%) and dislocations (4.4% vs. 1.3%) than the PTS group.

Conclusion

Transitioning from a PTS to an AS could reduce the PFF rate and other adverse events in hip arthroplasty. The findings are relevant for hospitals treating older and frail patients, as the mean age in this study was >80 years. Further research in different settings is warranted to confirm these results.

Level of Evidence

Level II.

An Uncommon Deformity of the Collarless, Polished, Double-Taper (CPT) Stem After a Periprosthetic Fracture in Total Hip Arthroplasty

We present an uncommon case of a Collarless, Polished, Double-Taper (CPT) stem deformity (irreversible stem bending) occurring due to a Periprosthetic Fracture (PPF) in Total Hip Arthroplasty (THA). The entire course of the case, including treatment, risk factors, and failure analysis of the deformed CPT by its manufacturer, Zimmer Biomet (Warsaw, USA),is described. The discussion considers in detail the (risk) factors that led to this particular stem deformity, incorporating current literature. We conclude with learning points on how to prevent stem abnormalities in PPFs in the future.  In our case, there were some case-specific risk factors associated with bending of the CPT stem. These factors are a relative varus angle, relative under-sizing of the stem, and a potentially inadequate cement mantle around the primary stem. No material or manufacture failure of the stem could be found. Still, it is very unusual that the femoral stem deforms without fracturing. Taken together, we present a unique case of a Periprosthetic Fracture with CPT stem deformity following Total Hip Arthroplasty.

Relating total hip replacement and acetabular cup positioning with outcome: A systematic review

The diverse methodologies employed in assessing cup placement, delineate the recommended target zones for positioning and examine the correlation between cup positioning and occurrences of complications is of interest. We included 51,308 patients and 51,692 hips for this analysis. The overall complication rate was 22.2%. Patients, overall, demonstrated improved outcomes, as evidenced by postoperative hip scores. Two "safe windows" have been defined for surgical procedures: 1) an inclination of 35-50 degrees and an anteversion of 5-25 degrees and 2) an inclination of 35-50 degrees and an anteversion of 15-25 degrees.

Periprosthetic fractures around cemented hip hemiarthroplasty: Are SOFCOT-Vancouver recommendations mandatory? A comparative study with propensity score matching

INTRODUCTION

Periprosthetic hip fracture is a serious complication associated with increased mortality and impaired autonomy. When the implant is loosened, the standard treatment involves prosthetic revision. However, recent studies suggest that these cases can be successfully treated with fixation without prosthetic exchange. This strategy seems relevant for elderly and frail patients with fractures around hemiarthroplasties but it has not yet been investigated in France. Therefore we did a retrospective comparative investigation aiming to compare postoperative complications (i.e., death within one month or reintervention) between osteosynthesis and prosthetic revision in elderly patients with Vancouver B fractures around polished tapered stem hemiarthroplasties.

HYPOTHESIS

We hypothesized that there would be no significant difference between osteosynthesis and prosthetic revision.

MATERIALS AND METHODS

In a single-university-center, all patients treated between 2005 and 2024 for periprosthetic fractures after cemented hemiarthroplasty were included in a retrospective observational study. A total of 92 patients were included, with an average age of 88.7 years (range, 77-107), mostly institutionalized (58%) and with multiple comorbidities, as indicated by a mean ASA score of 2.75 (range: 2-4) and a mean Charlson Comorbidity Index of 6.4 (range: 4-10); the average time between HHA and PPF occurrence was 2.1 years (range: 7-5679 days). The primary outcome was a composite criterion including the occurrence of a complication requiring reintervention or death within one month postoperatively. Group comparability was established using a propensity score.

RESULTS

The mean follow-up was 665 days, with the longest follow-up reaching 5704 days. No significant difference was observed in the primary outcome between the osteosynthesis group (n = 19/39 patients, (48.71%)) and the revision group (n = 16/39 patients, (41.02%)) (p = 0.637). Osteosynthesis demonstrated significantly shorter operative time (96 min vs. 167 min, p < 0.001), reduced blood loss (428 mL vs. 874 mL, p < 0.001), shorter hospital stays (9.17 days vs. 13.39 days, p < 0.001), and better autonomy preservation (loss of 1.09 Parker score points vs. 1.97 points, p < 0.001) compared to revision surgery. The 1-year mortality rate was 29,3% (27/92). The reintervention rate was 27.2% (25/92). The main causes of reintervention were dislocations, accounting for 13% (12/92) of cases, (occurring in 9.4% (5/53) of patients in the osteosynthesis group and 17.9% (7/39) in the revision group. The second most common reintervention cause was infection, which accounted for 11% (10/92) of cases, (occurring in 7.5% (4/53) of patients in the osteosynthesis group and 15.4% (6/39) in the revision group).

DISCUSSION

This result supports the idea that, for HHA's PPF, the Vancouver-SOFCOT recommendations can be adapted. For all type B fractures, if the fracture can be reduced and the cement mantle is well-fixed to the bone and of good quality, osteosynthesis is also a reliable option.

LEVEL OF EVIDENCE

III; Retrospective comparative study.

Post-operative periprosthetic femoral fractures in England: Patient profiles and short-term outcomes

BACKGROUND AND OBJECTIVE

Post-operative periprosthetic femoral fractures (POPFF) present a growing challenge for healthcare services, but there are limited national data on patient profiles, short-term outcomes, and post-discharge follow-up. We aimed to fill these gaps.

METHODS

Using Hospital Episode Statistics (HES), we identified POPFF discharges from hospitals in England for patients aged 18 and above between April 2016 and December 2022. We flagged prior admissions for hip fracture and elective hip or knee replacement surgery (primary, revision or re-revision) between April 2000 and the day of the POPFF admission date. We extracted information on patient factors, treatment modes for POPFF (nonoperative, fixation, revision), and outcomes (in-hospital mortality, length of stay, unplanned readmission). We used outpatient data to summarise post-hospitalisation follow-up.

RESULTS

Of 39,035 cases, 65.9 % were female; the median age was 82 years. HES data identified that 34.0 % had previously undergone elective hip replacement, 26.2 % elective knee replacement, and 22.8 % surgery for hip fracture. Those with a prior hip fracture were more likely to have delirium during the index POPFF admission, and, compared with those with a prior elective hip or knee replacement, they faced higher in-hospital mortality (5.1 % vs 3.2 % and 3.6 %, respectively), rates of readmission (15.4 % vs 13.1 % and 12.8 %, respectively), and hip re-fracture after POPFF (2.9 % vs 1.2 % and 1.6 %, respectively). Their median length of stay was longer (16 vs 14 days, p < 0.001). The most common reason for hospital readmission following POPFF was another fracture (11.3 % of all readmissions). Overall, 74 % of patients were discharged from outpatient follow-up within 12 months.

CONCLUSION

This is the first national description of the burden of adverse outcomes for people with POPFF in England, of whom a large proportion require ongoing specialist support. Fewer POPFF cases follow prior hip fracture surgery than elective joint replacement, but these patients face higher risks of worse outcomes. With an expected increasing incidence of POPFF, this may have considerable health service implications.

Risk factors for one-year mortality in 440 femoral peri-implant fractures: insights from the PIPPAS prospective, multicentre, observational study

Aims

The Peri-Implant and PeriProsthetic Survival AnalysiS (PIPPAS) study aimed to investigate the risk factors for one-year mortality of femoral peri-implant fractures (FPIFs).

Methods

This prospective, multicentre, observational study involved 440 FPIF patients with a minimum one-year follow-up. Data on demographics, clinical features, fracture characteristics, management, and mortality rates were collected and analyzed using both univariate and multivariate analyses. FPIF patients were elderly (median age 87 years (IQR 81 to 92)), mostly female (82.5%, n = 363), and frail: median clinical frailty scale 6 (IQR 4 to 7), median Pfeiffer 4 (1 to 7), median age-adjusted Charlson Comorbidity Index (CCI) 6 (IQR 5 to 7), and 58.9% (n = 250) were American Society of Anesthesiologists grade III.

Results

Overall, 90.5% (n = 398) of the patients were treated surgically, 57.0% (n = 227) retained the implant, and 88.7% (n = 353) managed with fixation. Mortality rates were 8.2% (n = 3.6) in-hospital, 11.4% (n = 50) at 30 days, 21.1% (n = 93) at six months, and 21.6% (n = 95) at 12 months. Medical complications, mainly delirium, were common in the acute setting (52.7%, n = 215). The nonunion rate was 4.1% (n = 18). Mortality risk factors in the univariate analysis were age, living at a nursing home, no walking outdoors, frailty variables, fractures in the distal epiphysis, fractures around a proximal nail, discharge to a healthcare facility, and no osteoporotic treatment at discharge. Protective factors against mortality in the univariate analysis were surgical treatment by an experienced surgeon, management without an arthroplasty, allowing full weightbearing, mobilization in the first 48 hours postoperatively, and geriatric involvement. Risk factors for mortality in the multivariate analysis were cognitive impairment (Pfeiffer's questionnaire) (hazard ratio (HR) 1.14 (95% CI 1.05 to 1.23), p = 0.002), age-adjusted CCI (HR 1.18 (95% CI 1.07 to 1.30), p = 0.001), and antiaggregant or anticoagulant medication at admission (HR 2.00 (95% CI 1.19 to 3.38), p = 0.009). Haemoglobin level at admission was protective against mortality (HR 0.85 (95% CI 0.74 to 0.97), p = 0.018).

Conclusion

Mortality in FPIFs occurs mainly within the first six months of follow-up. Early co-management and clinical optimization, particularly targeting frail older patients, is crucial in reducing mortality following these fractures.

Open reduction and internal fixation offers lower hip-related complications compared to stem revision in Vancouver B2 fractures around cemented polished tapered femoral stems

Purpose

Periprosthetic femoral fractures (PFFs) after total hip arthroplasty (THA) are increasing, particularly Vancouver B2 fractures around cemented polished tapered femoral stems. Open reduction and internal fixation (ORIF) are more frequently used in comparison to the traditional stem revision to deal with these complex fractures. This observational study aims to compare the outcomes of ORIF versus stem revision in the treatment of Vancouver B2.

Methods

A retrospective cohort study was conducted at Danderyd Hospital, Stockholm, from 2008 to 2022, including 157 patients (mean age 83.4 ± 7.0 years, 59% females) with a surgically treated Vancouver B2 fractures with an intact bone-cement interface. The study assessed the immediate and long-term outcomes of ORIF versus stem revision, examining post-operative complications, reoperation rates, and implant survivorship.

Results

Among the 157 patients, 37 were treated with ORIF and 120 with stem revision. The ORIF group, which consisted of older patients and had a higher prevalence of cognitive dysfunction, experienced no hip-related adverse events. In contrast, the revision group had a 17.8% incidence of adverse events. Mortality within 90 days was significantly higher in the ORIF group (24%) compared to the revision group (4%) (p = 0.0007). One-year mortality was also higher in the ORIF group (32%) than in the revision group (15%) (p = 0.03).

Conclusions

ORIF presents as a viable option for managing Vancouver B2 fractures in the proximity of a polished tapered stem when anatomical reduction is possible. The less invasive surgery provides potential advantages in patient outcomes and resource utilization. Further research is warranted to aid in the development of treatment guidelines.

Level of Evidence

III.

Vancouver B2 Periprosthetic femoral fractures around cemented polished taper-slip stems - how should we treat these? A systematic scoping review and algorithm for management

BACKGROUND

Periprosthetic femoral fractures (PFF) are a challenging complication of hip arthroplasty surgery, posing a high risk of morbidity, mortality and reoperation. The Vancouver Classification describes a B2 PFF around a loose stem with sufficient bone stock. In recent years, the number of B2 PFFs and cementation of femoral stems have increased substantially.

HYPOTHESIS

This systematic scoping review aimed to review the options available to surgeons in managing Vancouver B2 PFFs around cemented polished taper-slip (PTS) stems and establish an algorithm of management to treat varying fracture presentations.

PATIENTS AND METHODS

This study reviewed articles reporting on Vancouver B2 PFFs around cemented femoral stems between 2012 and 2022. Data extracted included: patient demographics, index prosthesis, surgical intervention and decision for treatment, operation time, transfusion requirement, length of hospital stay, post-operative rehabilitation protocol, mobility outcomes, radiological outcomes, complications, reoperations, mortality rates and follow-up.

RESULTS

In total, fourteen studies met all inclusion criteria including 552 cases. Mean patient age was 76.8 years with a male:female ratio 1:1.83 and median follow-up 49.2 months. Treatment options included open reduction and internal fixation (ORIF), revision arthroplasty using cementless modular and monoblock long-stems ± distal locking, cement-in-cement revision and cemented long-stem revision ± impaction bone grafting.

CONCLUSIONS

Management of B2 PFFs around cemented PTS stems is complex and aims to obtain stable fracture and stem fixation. Options include ORIF, cement-in-cement and cementless revision. The optimal choice depends on a combination of patient, fracture and surgeon factors. This review has proposed an algorithm to aid in decision making.

LEVEL OF EVIDENCE

III; systematic scoping review.

Open Reduction and Internal Fixation Is a Feasible Alternative to Femoral Revision Arthroplasty in Geriatric Patients with Vancouver B2/3 Type Periprosthetic Fractures: A Study Analyzing In-Hospital Outcomes

Purpose: The surgical management of periprosthetic femoral fractures is particularly challenging in geriatric patients due to physiological limitations. The choice between open reduction and internal fixation (ORIF) and hip revision arthroplasty for treating Vancouver B2 and B3 fractures remains controversial. This study aims to contribute further evidence by analyzing the in-hospital outcomes in geriatric patients with Vancouver B2/3 fractures. Methods: This retrospective study analyzed 133 patients treated for Vancouver B2/3 fractures at a level I trauma center from 2017 to 2023. Data were collected on preclinical characteristics, comorbidities, Vancouver classification, surgery-related parameters, and postoperative outcomes for an age- and gender-matched analysis. A subgroup analysis was also conducted on patients classified as American Society of Anesthesiologists (ASA) class 3 and 4. Results: Among the 133 patients, 85 suffered Vancouver B2 fractures and 48 Vancouver B3 fractures. Age-and-gender-matched analysis revealed that ORIF was more commonly performed in patients with higher ASA grades. A subgroup analysis of ASA 3 and 4 patients and an age-and-gender-matched analysis showed that ORIF resulted in shorter operation times and less blood loss. No significant differences were found in mortality or complication rates. Conclusions: ORIF is associated with shorter operation times, less bleeding, and comparable in-hospital outcomes in treating Vancouver B2/3 fractures in higher-risk geriatric patients compared to revision arthroplasty. The retrospective design and small sample size in the ORIF group are limitations of the study. Further studies with functional evaluation are still required.

Stem revision vs. internal fixation in Vancouver B2/B3 periprosthetic hip fractures: systematic review and metanalysis

INTRODUCTION

Vancouver B2 and B3 periprosthetic fractures (PFF) are associated with stem instability and often require a demanding stem implant revision (SR) or internal fixation (ORIF). This latter surgery is increasingly performed in the last few years instead of SR, but it is unclear which is the best treatment to manage PFF patients. The aim of this study is the compare the outcomes of B2/B3 PFF managed by either ORIF or SR, by performing a systematic review and meta-analysis of current literature.

MATERIALS AND METHODS

Cochrane Database, PubMed, Google Scholar and MEDLINE were examined to find out relevant publications dealing with the different outcomes of SR vs. ORIF in B2/B3 PFF of the hip. The effect model (EM) was calculated using Cohen´s d index.

RESULTS

Fifteen studies were included, reporting on a total of 1629 patients (564 ORIF and 1065 SR). The pooled random EM estimates for reoperation was 0.87 (95% CI, 0.39-1.96; I2 = 78%) in favor of ORIF surgery; EM for complications was 1.01 (95% CI, 0.45-2.27; I2 = 85%) without difference among procedures. The EM for transfusion was 0.72 (95% CI, 0.46-1.12; I2 = 62%) in favor of fixation.

CONCLUSION

ORIF and SR were both suitable and effective options in PFF patients, being associated to similar complications rates. Our results show that ORIF performance in PFF patients is associated to significantly less in blood loss, surgical time and in-hospital stay. These advantages are particularly appealing in patients with multiple comorbidities.

The History of Classification Systems for Periprosthetic Femoral Fractures: A Literature Review

Periprosthetic femoral fractures (PPFFs) following total hip arthroplasty (THA) present a significant clinical challenge due to their increasing incidence with an aging population and evolving surgical practices. Historically, classifications were primarily based on anatomical fracture location, the stability of the implant, and bone quality surrounding the implant. We critically analyzed 25 classification systems, highlighting the emergence and adaptations of key systems such as the Vancouver classification system (VCS) and the Unified classification system (UCS), which are lauded for their simplicity and effectiveness yet require further refinement. VCS, developed in 1995, categorizes fractures based on the site, implant stability, and bone quality, and remains widely used due to its robust applicability across different clinical settings. Introduced in 2014, UCS expands the VCS to encompass all periprosthetic fractures with additional fracture types, aiming for a universal application. Despite their widespread adoption, these systems exhibit shortcomings, including the incomplete inclusion of all PPFF types and the imprecise assessment of implant stability and surrounding bone loss. These gaps can result in misclassification and suboptimal treatment outcomes. This paper suggests the necessity for ongoing improvements in classification systems to include emerging fracture types and refined diagnostic criteria, ensuring that they remain relevant to contemporary orthopedic practices and continue to facilitate the precise tailoring of treatment to patient-specific circumstances. This comprehensive historical review serves as a foundation for future innovations in classification systems, ultimately aiming to standardize PPFF treatment and improve patient prognosis.

Comparative outcomes of uncemented and cemented stem revision in managing periprosthetic femoral fractures: a retrospective cohort study

INTRODUCTION

Periprosthetic femoral fractures (PFFs) following hip arthroplasty, especially Vancouver B2 and B3 fractures, present a challenge due to the association with a loose femoral stem, necessitating either open reduction and internal fixation or stem revision. This study aims to compare outcomes between uncemented and cemented stem revisions in managing Vancouver B2 and B3 fractures, considering factors such as hip-related complications, reoperations, and clinical outcome.

METHODS

A retrospective cohort study was conducted at Danderyd Hospital, Sweden, from 2008 to 2022, encompassing operatively treated Vancouver B2 and B3 fractures. Patients were categorized into uncemented and cemented stem revision groups, with data collected on complications, revision surgeries, fracture healing times, and clinical outcomes.

RESULTS

A total of 241 patients were identified. Significant differences were observed between the two groups in patient demographics, with the cemented group comprising older patients and more females. Follow up ranged from 1 to 15 years. Average follow up time was 3.9 years for the cemented group and 5.5 years for the uncemented group. The cemented stems demonstrated lower rates of dislocation (8.9% versus 22.5%, P = 0.004) and stem loosening (0.6% versus 9.3%, P = 0.004) than the uncemented method. Moreover, the cemented group exhibited shorter fracture healing times (11.4 weeks versus 16.7 weeks, P = 0.034). There was no difference in clinical outcome between groups. Mortality was higher in the cemented group.

CONCLUSIONS

This retrospective study indicates that cemented stem revision for Vancouver B2-3 fractures is correlated with lower dislocation and stem loosening rates, necessitating fewer reoperations and shorter fracture healing times compared with the uncemented approach. The cemented group had a notably higher mortality rate, urging caution in its clinical interpretation.

LEVEL OF EVIDENCE III

Birmingham Hip Resurfacing at 25 years

Aims

The Birmingham Hip Resurfacing (BHR) was introduced in 1997 to address the needs of young active patients using a historically proven large-diameter metal-on-metal (MoM) bearing. A single designer surgeon's consecutive series of 130 patients (144 hips) was previously reported at five and ten years, reporting three and ten failures, respectively. The aim of this study was to extend the follow-up of this original cohort at 25 years.

Methods

The study extends the reporting on the first consecutive 144 resurfacing procedures in 130 patients for all indications. All operations were undertaken between August 1997 and May 1998. The mean age at operation was 52.1 years (SD 9.93; 17 to 76), and included 37 female patients (28.5%). Failure was defined as revision of either component for any reason. Kaplan-Meier survival analysis was performed. Routine follow-up with serum metal ion levels, radiographs, and Oxford Hip Scores (OHSs) was undertaken.

Results

Overall implant survival was 83.50% (95% confidence interval (CI) 0.79 to 0.90) at 25 years, and the number at risk was 79. Survival in male patients at 25 years was 89.5% (95% CI 0.83 to 0.96) compared to 66.9% for female patients (95% CI 0.51 to 0.83). Ten additional failures occurred in the period of ten to 25 years. These involved an adverse reaction to metal debris in four patients, a periprosthetic femoral neck fracture affecting five patients, and aseptic loosening in one patient. The median chromium levels were 49.50 nmol/l (interquartile range (IQR) 34 to 70), and the median cobalt serum levels were 42 nmol/l (IQR 24.50 to 71.25). The median OHS at last follow-up was 35 (IQR 10 to 48). During the 25-year study period, 29 patients died. Patient survival at 25 years was 75.10% (95% CI 0.67 to 0.83).

Conclusion

This study demonstrates that MoM hip resurfacing using the BHR provides a durable alternative to total hip arthroplasty (THA), particularly in younger male patients with osteoarthritis wishing to maintain a high level of function. These results compare favourably to the best results for THAs.

Health status after periprosthetic proximal femoral fractures

Aims

Periprosthetic proximal femoral fractures (PFFs) are a major complication after total hip arthroplasty (THA). Health status after PFF is not specifically investigated. The aim of this study is to evaluate the health status pattern over two years after sustaining a PFF.

Methods

A cohort of patients with PFF after THA was derived from the Brabant Injury Outcomes Surveillance (BIOS) study. The BIOS study, a prospective, observational, multicentre follow-up cohort study, was conducted to obtain data by questionnaires pre-injury and at one week, and one, three, six, 12, and 24 months after trauma. Primary outcome measures were the EuroQol five-dimension three-level questionnaire (EQ-5D-3L), the Health Utility Index 2 (HUI2), and the Health Utility Index 3 (HUI3). Secondary outcome measures were general measurements such as duration of hospital stay and mortality.

Results

A total of 70 patients with a PFF were included. EQ-5D utility scores were significantly lower on all timepoints except at six months' follow-up compared to pre-injury. EuroQol visual analogue scale (EQ-VAS) scores at one month's follow-up were significantly lower compared to pre-injury. The percentage of reported problems at two years was higher for all dimensions except anxiety/depression when compared to pre-injury. The mean EQ-5D utility score was 0.26 higher in males compared to females (95% confidence interval (CI) 0.01 to 0.42; p = 0.003). The mean EQ-VAS score for males was 8.9 points higher when compared to females over all timepoints (95% CI 1.2 to 16.7; p = 0.027). Mortality was 10% after two years' follow-up.

Conclusion

PFF patients are a frail population with substantial functional impairment at baseline. Post-injury, they have a significant and clinically relevant lower health status two years after trauma when compared to pre-injury. Health status improves the most between one and three months after injury. Two years after PFF, more patients experience problems in mobility, self-care, usual activities, and pain/discomfort than pre-injury.

Vancouver B2 periprosthetic hip fractures treatment: fix or replace? A retrospective study comparing both techniques

INTRODUCTION

Vancouver B2 periprosthetic hip fractures involve stem stability and they have been classically treated with revision surgery. Crucial factors such as age, clinical comorbidities and functional status are often neglected. The current study aims to compare clinical outcomes between patients treated with open reduction and internal fixation (ORIF) or femoral stem exchange.

METHODS

This is a retrospective study that includes all Vancouver B2 periprosthetic hip fractures in a tertiary referral hospital from 2016 to 2020. Patients were divided into two groups: Group 1. Patients treated with an ORIF and Group 2. Patients treated with stem replacement. The outcomes that were compared between groups included demographic data, functional capacity, complications and mortality.

RESULTS

29 periprosthetic Vancouver B2 fractures were finally analyzed. 11 (37.9%) were treated with ORIF (Group 1) and 18 (62.1%) by stem replacement (Group 2). Surgery time (143 vs. 160 min), hemoglobin drop (1.8 vs. 2.5 g/dL) and hospital stance (25.5 vs. 29.6 days) were shorter in Group 1. According to complications, 18.2% of patients in the ORIF group had orthopedic complications compared with 44.4% in the revision group. In the revision group, 3 cases needed a two-stage revision and one of these revisions ended up with a resection arthroplasty (Girdlestone). The first-year mortality rate was 27% in Group 1 and 11% in Group 2.

DISCUSSION

ORIF treatment seems to be a less aggressive and complex procedure which can lead to a faster general recovery. Revision surgery can imply a higher risk of orthopedic complications which can be severe and may require further aggressive solutions. The ORIF group mortality was similar to the proximal femur fracture rate (20-30%). In conclusion, ORIF treatment seems to be a good option especially in fragile patients with low functional demand when anatomical reduction is possible.

Risk factors influencing periprosthetic fracture and mortality in elderly patients following hemiarthroplasty with a cemented collarless polished taper stem for an intracapsular hip fracture

Aims

The aims of this study were to evaluate the incidence of reoperation (all cause and specifically for periprosthetic femoral fracture (PFF)) and mortality, and associated risk factors, following a hemiarthroplasty incorporating a cemented collarless polished taper slip stem (PTS) for management of an intracapsular hip fracture.

Methods

This retrospective study included hip fracture patients aged 50 years and older treated with Exeter (PTS) bipolar hemiarthroplasty between 2019 and 2022. Patient demographics, place of domicile, fracture type, delirium status, American Society of Anesthesiologists (ASA) grade, length of stay, and mortality were collected. Reoperation and mortality were recorded up to a median follow-up of 29.5 months (interquartile range 12 to 51.4). Cox regression was performed to evaluate independent risk factors associated with reoperation and mortality.

Results

The cohort consisted of 1,619 patients with a mean age of 82.2 years (50 to 104), of whom 1,100 (67.9%) were female. In total, 29 patients (1.8%) underwent a reoperation; 12 patients (0.7%) sustained a PFF during the observation period (United Classification System (UCS)-A n = 2; UCS-B n = 5; UCS-C n = 5), of whom ten underwent surgical management. Perioperative delirium was independently associated with the occurrence of PFF (hazard ratio (HR) 5.92; p = 0.013) and surgery for UCS-B PFF (HR 21.7; p = 0.022). Neither all-cause reoperation nor PFF-related surgery was independently associated with mortality (HR 0.66; p = 0.217 and HR 0.38; p = 0.170, respectively). Perioperative delirium, male sex, older age, higher ASA grade, and pre-fracture residential status were independently associated with increased mortality risk following hemiarthroplasty (p < 0.001).

Conclusion

The cumulative incidence of PFF at four years was 1.1% in elderly patients following cemented PTS hemiarthroplasty for a hip fracture. Perioperative delirium was independently associated with a PFF. However, reoperation for PPF was not independently associated with patient mortality after adjusting for patient-specific factors.

Analysis of complications in 97 periprosthetic Vancouver B2 fractures treated either by internal fixation or revision arthroplasty

INTRODUCTION

The treatment of Vancouver B2 periprosthetic fractures after hip arthroplasty is still a matter of debate. Revision Arthroplasty (RA) was long thought to be the treatment of choice, however several recent papers suggested that Open Reduction and Internal Fixation (ORIF) is a viable option for selected B2 fractures. Complication rates of 14-26% have been reported following surgical treatment of B2 fractures. No significant difference between RA and ORIF in the complication rates nor in the functional outcome was observed.

METHOD

We conducted a retrospective analysis of 97 consecutive Vancouver B2 fractures treated according to the algorithm at our institution from 2007 to 2020 and recorded complications and patient specific data.

RESULT

From the 97 patient, 45 fractures were treated with RA while 52 fractures were treated with ORIF. Thirteen patients in the RA group had a complication that needed revision (28%) and 11 patients in the ORIF group needed revision (21%). There was no significant difference between complication rates. The reason for failure in the 13 RA patients were infection (n = 4), stem subsidence (n = 1), refracture after a new fall (n = 3), secondary dislocation of the greater trochanter (n = 1) and dislocation (n = 4). The reason for failure in the 11 ORIF patients that were revised were infection (n = 5), persistent symptomatic stem loosening (n = 3) and refracture (n = 3) after a new fall.

CONCLUSION

ORIF can be used to revise cemented and non-cemented shafts in more than half of Vancouver B2 fractures with no difference in complication rates when compared to RA. A periprosthetic fracture around the hip has a 21-28% risk of a re-operation after revision surgery with infection and re-fracture after a new fall being the most frequent cause of re-operation.

Risk factors for periprosthetic femoral fracture risk around a cemented polished taper-slip stem using an osteoporotic composite bone model

This biomechanical study aimed to determine if variations in stem material, stem geometry, stem offset and cement viscosity affect mechanical resistance to postoperative periprosthetic fracture (PFF) after hip arthroplasty with a commonly used cemented polished taper-slip (PTS) stem (CPT, Zimmer Biomet) in a novel osteoporotic composite femoral bone model. Thirty-six osteoporotic composite femoral models were tested using a standardised in-vitro loading technique to simulate a typical PFF. Outcome measures were torque to failure (N), fracture energy (N/m2) and rotation to failure (°). Comparisons were made by stem material (cobalt chrome vs stainless steel), stem geometry (CPT stem vs Exeter stem), stem offset (standard offset vs extra extended offset) and cement viscosity (high viscosity vs low viscosity). Statistical comparisons were carried out with significance set at p < 0.05. All tested samples produced clinically representative fracture patterns with varying degrees of bone and cement comminution. There was no statistically significant difference in torque to failure, fracture energy or rotation to failure between any of the compared variables (all p > 0.05). This is the first biomechanical study on mechanical resistance to PFF using osteoporotic composite bone models. For the CPT stem, it confirms that stem material, stem offset, stem geometry and cement viscosity do not affect mechanical resistance to PFF in an osteoporotic bone model.

Reoperation risk of periprosthetic fracture after primary total hip arthroplasty using a collared cementless or a taper-slip cemented stem

Aims

The aim of this study was to determine both the incidence of, and the reoperation rate for, postoperative periprosthetic femoral fracture (POPFF) after total hip arthroplasty (THA) with either a collared cementless (CC) femoral component or a cemented polished taper-slip (PTS) femoral component.

Methods

We performed a retrospective review of a consecutive series of 11,018 THAs over a ten-year period. All POPFFs were identified using regional radiograph archiving and electronic care systems.

Results

A total of 11,018 THAs were implanted: 4,952 CC femoral components and 6,066 cemented PTS femoral components. Between groups, age, sex, and BMI did not differ. Overall, 91 patients (0.8%) sustained a POPFF. For all patients with a POPFF, 16.5% (15/91) were managed conservatively, 67.0% (61/91) underwent open reduction and internal fixation (ORIF), and 16.5% (15/91) underwent revision. The CC group had a lower POPFF rate compared to the PTS group (0.7% (36/4,952) vs 0.9% (55/6,066); p = 0.345). Fewer POPFFs in the CC group required surgery (0.4% (22/4,952) vs 0.9% (54/6,066); p = 0.005). Fewer POPFFs required surgery in males with a CC than males with a PTS (0.3% (7/2,121) vs 1.3% (36/2,674); p < 0.001).

Conclusion

Male patients with a PTS femoral component were five times more likely to have a reoperation for POPFF. Female patients had the same incidence of reoperation with either component type. Of those having a reoperation, 80.3% (61/76) had an ORIF, which could greatly mask the size of this problem in many registries.

Does size matter? Outcomes following revision total hip arthroplasty with long or primary stems: a systematic review and meta-analysis

BACKGROUND

Femoral reconstruction with long stems is widely accepted as the standard in revision total hip arthroplasty (rTHA). However, long stems can be technically challenging to insert and can compromise bone stock for future revision. This study aimed to identify whether there was a difference in outcomes with using a long versus primary or short femoral stem in revision.

METHODS

We performed a systematic review and meta-analysis of all articles comparing long and primary stem length in rTHA for Paprosky 1-3B femoral defects. The primary outcome measure was the reoperation rate after rTHA. Secondary outcomes included infection and dislocation rates, periprosthetic fracture, loosening, mortality, and patient-reported outcome measures (PROMs).

RESULTS

The results of 3,102 rTHAs performed in 2,982 patients were reported from 9 eligible studies in the systematic review, of which 6 were included in the meta-analysis. The mean patient age was 67.4 and the mean follow-up lasted 5 years (range, 1-15 years). There was no significant difference in the reoperation rate (odds ratio 0.78; 95% confidence interval, 0.28-2.17, P = 0.63). Similarly, there was no significant difference in dislocation or periprosthetic fracture risk. Harris Hip Score was better with primary stems by a mean difference of 14.4 points (P < 0.05). Pooled 5-year stem-related survival was 91.3% ± 3.5% (SD) for primary stems and 89.9% ± 6.7% (SD) for long stems.

CONCLUSIONS

A primary stem provided non-inferior outcomes compared with long stems in rTHA with Paprosky type 1-3B femoral defects. Primary stems may yield a more straightforward technique and preserve distal bone stock for future revision particularly in younger patients. In older patients with lower functional demands and who would benefit from a decreased risk of complications, a long cemented stem is recommended.

Cemented femoral stem design and postoperative periprosthetic fracture risk following total hip arthroplasty

Polished taper-slip (PTS) cemented stems have an excellent clinical track record and are the most common stem type used in primary total hip arthroplasty (THA) in the UK. Due to low rates of aseptic loosening, they have largely replaced more traditional composite beam (CB) cemented stems. However, there is now emerging evidence from multiple joint registries that PTS stems are associated with higher rates of postoperative periprosthetic femoral fracture (PFF) compared to their CB stem counterparts. The risk of both intraoperative and postoperative PFF remains greater with uncemented stems compared to either of these cemented stem subtypes. PFF continues to be a devastating complication following primary THA and is associated with high complication and mortality rates. Recent efforts have focused on identifying implant-related risk factors for PFF in order to guide preventative strategies, and therefore the purpose of this article is to present the current evidence on the effect of cemented femoral stem design on the risk of PFF.

Surgical approaches to periprosthetic femoral fractures for plate fixation or revision arthroplasty

Periprosthetic femoral fractures are increasing in incidence, and typically occur in frail elderly patients. They are similar to pathological fractures in many ways. The aims of treatment are the same, including 'getting it right first time' with a single operation, which allows immediate unrestricted weightbearing, with a low risk of complications, and one that avoids the creation of stress risers locally that may predispose to further peri-implant fracture. The surgical approach to these fractures, the associated soft-tissue handling, and exposure of the fracture are key elements in minimizing the high rate of complications. This annotation describes the approaches to the femur that can be used to facilitate the surgical management of peri- and interprosthetic fractures of the femur at all levels using either modern methods of fixation or revision arthroplasty.

Which Unified Classification System type B periprosthetic fractures around cemented polished tapered stems should not be fixed?

The Unified Classification System (UCS), or Vancouver system, is a validated and widely used classification system to guide the management of periprosthetic femoral fractures. It suggests that well-fixed stems (type B1) can be treated with fixation but that loose stems (types B2 and B3) should be revised. Determining whether a stem is loose can be difficult and some authors have questioned how to apply this classification system to polished taper slip stems which are, by definition, loose within their cement mantle. Recent evidence has challenged the common perception that revision surgery is preferable to fixation surgery for UCS-B periprosthetic fractures around cemented polished taper slip stems. Indications for fixation include an anatomically reducible fracture and cement mantle, a well-fixed femoral bone-cement interface, and a well-functioning acetabular component. However, not all type B fractures can or should be managed with fixation due to the risk of early failure. This annotation details specific fracture patterns that should not be managed with fixation alone.

Factors associated with failure of fixation of Vancouver B fractures around a cemented polished tapered stem: A 5 to 14 year follow up study

AIMS

There is increasing evidence for fixation as opposed to revision for Vancouver B fractures around polished taper slip stems, however it is remains unclear whether fixation is associated with stem loosening in the longer term. This study aims to assess survival of plate-fixation of Vancouver-B-fractures around a polished-taper- slip cemented stem and identify factors associated with failure.

METHODS

Retrospective cohort study assessed 129 consecutive unilateral Vancouver-B-fractures around cemented Exeter stems at a minimum of 5 years following open-reduction-internal-fixation (ORIF) with unilateral non-locked unilateral plating+/-cerclage cables. The primary outcome measure was reoperation for any reason. Kaplan Meier survival analysis was performed.

RESULTS

Fractures (B1 n = 31 (24%); B2 n = 91 (71%); and B3 n = 7 (5%)) occurred at median of 6 years (IQR 1.2-9.2) after primary surgery. Mean patient age was 78.2 (SD10.56, range 46-96) and 54 (42.9%) were female. Mean follow up was 8.7 years (SD 2.48, 5.7 to 14.4). Symptomatic femoral stem loosening requiring revision occurred in two B2 fractures of metaphyseal split and short spiral patterns. The most common mode of failure was non-union (n = 7, 5%). Both fixation failure (n = 6/31 Vs n = 3/91 vs n = 0/7, p = 0.008) and reoperation (n = 8/31 vs n = 6/91 vs n = 0/7, p = 0.008) were significantly higher following fixation of B1 fractures compared to B2 and B3 fractures. Overall 5year survival free from reoperation was 88.8% (82.0-94.7 95%CI). B1 fracture types were associated with an increase risk of failure (endpoints fixation failure p = 0.010; and reoperation p = 0.016). Transverse fractures (B1) were associated with a relative risk of reoperation of 4.22 (1.63-10.9 95% CI, p = 0.008).

CONCLUSION

Fixation of Vancouver-B fractures around cemented Exeter stems, when the bone-cement interface is intact and the fracture is anatomically reducible, had an excellent 5-year survival. Only 2 (1.6%) cases of late femoral stem loosening occurred, however, B1 type transverse fractures were associated with a higher rate of reoperation.