Age as a Risk Factor for Intraoperative Periprosthetic Femoral Fractures in Cementless Hip Hemiarthroplasty for Femoral Neck Fractures: A Retrospective Analysis

Background

Understanding the risk factors and outcomes of intraoperative periprosthetic femoral fractures (IPFF) during hip arthroplasty is crucial for appropriate perioperative management. Previous studies have identified risk factors for IPFF in total hip arthroplasty patients, but data for hip hemiarthroplasty (HA) is lacking. The aim of this study was to determine the age associated with increased rates of IPFF in patients undergoing HA.

Methods

We retrospectively reviewed patients aged 65 years and above who underwent a cementless HA for a displaced femoral neck fracture and had a minimum of 1-year follow-up. Patients were stratified into five age groups (65-79, 80-84, 85-89, 90-94, and ≥ 95 years) and further divided into two subgroups (under 95 years and 95 years or older). The presence, location, and treatment of IPFF, as well as the effect of IPFF on the postoperative weight-bearing status, were compared between groups. A multivariate logistic regression was also performed. A total of 1,669 met the inclusion criteria and were included in the study.

Results

The rates of IPFF were significantly higher for patients 95 years or older (p = 0.030). However, fracture location (greater trochanter fractures, p = 0.839; calcar fractures, p = 0.394; and femoral shaft fractures p = 0.110), intraoperative treatment (p = 0.424), and postoperative weight-bearing status (p = 0.229) were similar between the groups. While mortality and nonorthopedic-related readmissions were significantly higher for patients 95 years or older, orthopedic-related readmissions (p = 0.148) and revisions at the latest follow-up (p = 0.253) were comparable between groups. In a regression analysis, age over 95 years (odds ratio, 2.049; p = 0.049) and body mass index (odds ratio, 0.935; p = 0.016) were independently associated with IPFF.

Conclusions

The findings of this study suggest that age over 95 years is a significant, independent risk factor for IPFF in patients undergoing cementless HA. Although we were unable to show an impact on perioperative outcomes and orthopedic complications, when operating on patients 95 years or older, surgeons should be aware of the increased risk of IPFF and consider the use of stem designs and fixation types associated with decreased IPFF rates.

Intraoperative Periprosthetic Fractures during primary Total knee arthroplasty: Experience from an Asian high-volume arthroplasty centre

BACKGROUND

Intraoperative periprosthetic fracture (IF) is an under-reported complication in primary total knee arthroplasty (TKA). This study aimed to audit the outcomes and complication rates in patients encountering IF during primary TKA and propose a new classification for its management.

METHODS

A nested case-control study was performed at a tertiary referral hospital where 50 patients encountering IF during primary TKA operated by a single surgeon team between January 2016 to May 2021, were compared with 150 (3:1) age-, gender- and implant-matched patients not encountering IF. Demographic data, risk factors, outcomes and complications of both groups were compared at a minimum follow up of 1 year.

RESULTS

The incidence of IF was 0.45%, with 44 fractures in the femur (88%), six (12%) in the tibia and none in the patella. Medial collateral ligament avulsion fracture (54.54%) in the femur and medial plateau fracture (66.66%) in the tibia were the most common fracture types. At final follow up, the fracture group had higher rates of 90-day re-admissions (8% vs. 2.66%, P = 0.095), deep infection (4% vs. 0.66%, P = 0.15) and revisions (6% vs. 1.33%, P = 0.06). The mean Knee Society Score was not significantly different between the two groups (152.22 ± 9.25 vs. 161.68 ± 11.22, P = 0.642) with union being achieved in all but one patient at a mean duration of 9.6 weeks.

CONCLUSIONS

Patients with severe and fixed deformities have a higher risk for IF. The occurrence of fracture and the complexity of surgery equally contribute to the higher complication rates. Appropriately managed fractures have comparable functional outcomes.

Intraoperative fractures in cephalomedullary nailing for trochanteric fractures

INTRODUCTION

Cephalomedullary nailing (CMN) is the standard treatment for internal fixation of trochanteric fractures. Complications related to CMN include intraoperative fracture (IF), which is difficult to detect using only plain radiographs. However, analyses of IFs using plain radiographs and computed tomography (CT) with a large sample size of clinical cases are lacking. Therefore, this study aimed to report the incidence of IFs diagnosed by CT, the risk factors for IFs, and a comparison of clinical outcomes between patients with and without IFs.

METHODS

This multicenter retrospective cohort study included 638 patients who underwent CMN fixation for trochanteric fractures. We evaluated IF using pre-and postoperative plain radiographs and CT. The primary outcome was reoperation and the secondary outcome was the proportion of patients who regained independent mobility at 3 months postoperatively. Furthermore, we conducted multivariable logistic regression analyses to examine the association between risk factors and IFs.

RESULTS

Seventy-five (11.8%) patients had IFs, including 53 patients with occult IFs (8.3%). The most common location of IF was at the interference with the lag screw entry (45.3%). The nail insertion procedure (17.3%) was the most common reason for IF. In the assessment of clinical outcomes, patients with IFs had no reoperations and independent mobility at postoperative 3 months was lower (69.6% vs. 79.1%). Regarding regaining independent walking in the IF group, IF distal to lag screw entry and obvious IF diagnosed with plain radiographs were poor factors. The multivariable analysis showed that only inadequate reduction on the anteroposterior view based on the plain radiograph was significantly associated with the incidence of IFs (odds ratio 3.91; 95% CI, 1.28-11.94; p = 0.017).

CONCLUSIONS

This multicenter study indicated that the incidence of IFs detected by CT in CMN treatment for trochanteric fractures was 11.8%. An inadequate reduction in the anteroposterior view based on plain radiographs was the only independent risk factor of IFs. In the assessment of clinical outcomes, patients with IF had no incidences of reoperation. However, patients with IFs tended not to regain independent mobility compared with those without IFs.

Fixation of intraoperative proximal femoral fractures during THA using two versus three cerclage wires - a biomechanical study

Background

Intraoperative proximal femoral fractures (IPFF) are relevant complications during total hip arthroplasty. Fixation using cerclage wires (CW) represents a minimally-invasive technique to address these fractures through the same surgical approach. The goal of treatment is to mobilise the patient as early as possible, which requires high primary stability. This study aimed to compare different cerclage wire configurations fixing IPFF with regard to biomechanical primary stability.

Methods

Standardised IPFF (type II, Modified Mallory Classification) were created in human fresh frozen femora and were fixed either by two or three CW (1.6 mm, stainless steel). All cadaveric specimens (n = 42) were randomised to different groups (quasi-static, dynamic) or subgroups (2 CW, 3 CW) stratified by bone mineral density determined by Dual Energy X-ray Absorptiometry. Using a biomechanical testing setup, quasi-static and dynamic cyclic failure tests were carried out. Cyclic loading started from 200 N to 500 N at 1 Hz with increasing peak load by 250 N every 100 cycles until failure occurred or maximum load (5250 N) reached. The change of fracture gap size was optically captured.

Results

No significant differences in failure load after quasi-static (p = 0.701) or dynamic cyclic loading (p = 0.132) were found between the experimental groups. In the quasi-static load testing, all constructs resisted 250% of the body weight (BW) of their corresponding body donor. In the dynamic cyclic load testing, all but one construct (treated by 3 CW) resisted 250% BW.

Conclusions

Based on this in vitro data, both two and three CW provided sufficient primary stability according to the predefined minimum failure load (250% BW) to resist. The authors recommend the treatment using two CW because it reduces the risk of vascular injury and shortens procedure time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04956-5.

Risk factors of dislocation after total hip arthroplasty in patients with developmental dysplasia of the hip

PURPOSE

Dislocation following total hip arthroplasty (THA) is a well-known complication. However, there is little data on its rate and predictors in patients with developmental dysplasia of the hip (DDH). The current study is aimed to determine the rate and specific risk factors of dislocation following THA in DDH patients.

METHODS

All the medico-surgical records of primary THAs from January 2014 to January 2019 were retrospectively reviewed. They were categorized into three main groups: primary OA, DDH, and others. Pre-operative and post-operative radiographs, past medical and surgical history, and surgical notes were reviewed in DDH cases.

RESULTS

In a total of 171 patients with DDH, 21 suffered from dislocation after THA (12%) which was significantly more frequent than those with primary OA. In univariate analysis, higher grade of dysplasia, smaller head size, intra-operative fracture, Wagner Cone stem, failure of offset restoration, and implanting the cup outside the Lewinnek's safe zone were identified as predictors of dislocation. In multiple regression analysis, however, only higher Crowe grade, intra-operative fracture, and post-operative acetabular offset less than 16 mm were independent predictors of dislocation.

CONCLUSION

Dysplastic hips can be more prone to post-THA dislocation than those with primary OA. Higher grades of dysplasia, failure of offset restoration, and intra-operative fracture can increase the rate of dislocation in this group of patients.

A study of femoral offset in the South Indian population and its clinical implications in hip arthroplasty

BACKGROUND

Recreation of the normal proximal femoral anatomy is paramount for a successful total hip arthroplasty. The study aims to look at whether the range of offset options available in the femoral stems available locally, would be adequate to restore the native femoral horizontal offset (FHO) of the South Indian population.

METHOD

This is a prospective single-center study of 1-year duration, where we study the FHO on radiographs and CT scans in 100 patients. We then look at the femoral stems available in the Indian market and see if the offset may be restored with the available stems.

RESULT

The FHO ranged from 23.3 to 46.9 mm with a mean of 35.7 ± 5.3 mm. The females in the group (33.86 ± 4.71 mm) had a lower FHO compared to males (37.78 ± 5. 21 mm). We found that 50% of the South Indian population and 62% of the females have an offset less than 35 mm. Among the 18 stems that we studied, four out of nine cemented and two out of nine uncemented stems did not offer an offset below 35 mm.

CONCLUSION

The native FHO in the South Indian population is significantly less than that of Caucasians. The surgeon should be aware that many implant systems available in India do not offer offset options in this range. In this group, even when a stem with smallest offset is used, there is a risk of increasing the FHO with a potential for intraoperative fractures due to difficult reduction and leg-lengthening. Hence, the surgeon should template carefully and choose only those implant systems which can offer an offset similar to the native offset to restore the anatomy accurately. We recommend that all manufacturers consider offering implants with smaller offset (25-35 mm).

Intraoperative Femoral Condyle Fracture during Bone Preparation in a Cruciate-retaining Primary Total Knee Arthroplasty

Introduction

Intraoperative fracture in revision knee arthroplasty is commonly described. Intraoperative fracture during primary total knee arthroplasty (TKA) is a significant yet infrequently reported complication. The literature about intraoperative fractures during primary TKA is limited. It is usually seen in posterior-stabilized prosthesis during primary TKA, however, its occurrence in cruciate-retaining (CR) primary TKA is rarely reported.

Case Report

The authors describe a unique case of intraoperative medial femoral condyle fracture in primary CR TKA during bone preparation. The fracture was managed successfully by fixation with a 3.5 mm screw followed by cemented primary CRTKA. Bony union was achieved with a good clinical outcome as shown by the Knee Society Knee Score of 86 and a Function Score of 90 without any signs of prosthesis failure/loosening at 2 years' follow-up.

Discussion

Careful pre-operative evaluation and planning are necessary for patients with risk factors to avoid poor outcome. A stable internal fixation abiding the standard principles of fracture fixation and arthroplasty is needed to achieve a satisfactory functional and radiographic outcome, thus avoids early prosthetic failure.

Intraoperative complications in total hip arthroplasty using a new cementless femoral implant (SP-CL®)

BACKGROUND

Considering the excellent results already achieved in total hip arthroplasty (THA), new implants must be at least as safe as currently used implants and lead to longer survival. A new cementless femoral stem, SP-CL^®, has been introduced. The aim of this study is to evaluate intraoperative complications and assess the risk factors of THA with the SP-CL^® implant.

MATERIALS AND METHODS

All THA patients who were operated on using the SP-CL^® (LINK, Hamburg, Germany) implant between 2015 and 2018 were included in the analysis. Data were collected from medical records from national and hospital electronic databases. Radiological measurements were made from standard pre- and postoperative radiographs.

RESULTS

A total of 222 THA were performed using the SP-CL^® implant. The average age of the patients was 56 years (14-77 years). There were 1 transient sciatic nerve injury, 1 acetabular fracture, and 11 (5.0%) intraoperative femoral fractures (IFF), of which 7 were treated with cerclage wire or titanium band during the operation while the other fractures were treated conservatively. None of the IFF patients were revised due to fracture during the follow-up period (one revision due to infection). The radiographic morphology of proximal femur was associated with increased risk of IFF (p = 0.02).

CONCLUSIONS

The results of the current study demonstrate a 5% incidence of IFF when using the LINK SP-CL^® femoral stem in THA. The radiographic morphology of the proximal femur was an important predictor of IFF and should be assessed when using SP-CL^®.

LEVEL OF EVIDENCE

Level 4.

Risk analysis and clinical outcomes of intraoperative periprosthetic fractures: a retrospective study of 481 bipolar hemiarthroplasties

BACKGROUND

Intraoperative periprosthetic fractures (IPF) are a well-described complication following hip hemiarthroplasty. Our aims were to identify risk factors that characterize IPF and to investigate postoperative mobility.

METHODS

We retrospectively reviewed 481 bipolar hemiarthroplasties for displaced femoral neck fractures; of which, 421 (87.5%) were performed without cement, from January 2013 to March 2018. Data on the patients' demographics, comorbidities, femoral canal geometry (Dorr canal type, Canal Flare Index), surgeon's experience (junior vs. senior surgeon), and timing of surgery (daytime vs. on-call duty) were obtained. In patients with intraoperative fractures, further information was obtained. Patient mobility was assessed using matched-pair analysis. Mobility was classified according to the NHFD mobility score. The chi-square test, Fisher's exact test, and Fisher-Freeman-Halton exact test were used for comparison between categorical variables, while the Mann-Whitney U test was used for continuous variables. The data analysis was performed using SPSS.

RESULTS

Of 481 procedures, 34 (7.1%) IPFs were encountered. The Dorr canal type C was identified as a significant risk factor (p = .004). Other risk factors included female sex (OR 2.30, 95% CI .872-6.079), stovepipe femur (OR 1.749, 95% CI .823-3.713), junior surgeon (OR 1.204, 95% CI .596-2.432), and on-call-duty surgery (OR 1.471, 95% CI .711-3.046), although none showed a significant difference. Of 34 IPFs, 25 (73.5%) were classified as Vancouver type A. The treatment of choice was cerclage wiring. Within the 12 matched pairs identified, the postoperative mobility was slightly worse for the IPF group (delta = .41).

CONCLUSIONS

IPF is a serious complication with bipolar hemiarthroplasty. The identification of risk factors preoperatively, in particular femur shape, is crucial and should be incorporated into the decision-making process.

Preoperative bisphosphonate treatment may adversely affect the outcome after shoulder arthroplasty

AIMS

The aim of this study was to investigate the effects of preoperative bisphosphonate treatment on the intra- and postoperative outcomes of arthroplasty of the shoulder. The hypothesis was that previous bisphosphonate treatment would adversely affect both intra- and postoperative outcomes.

PATIENTS AND METHODS

A retrospective cohort study was conducted involving patients undergoing arthroplasty of the shoulder, at a single institution. Two patients with no previous bisphosphonate treatment were matched to each patient who had received this treatment preoperatively by gender, age, race, ethnicity, body mass index (BMI), and type of arthroplasty. Previous bisphosphonate treatment was defined as treatment occurring during the three-year period before the arthroplasty. The primary outcome measure was the incidence of intraoperative complications and those occurring at one and two years postoperatively. A total of 87 patients were included: 29 in the bisphosphonates-exposed (BP⁺) group and 58 in the non-exposed (BP^-) group. In the BP⁺ group, there were 26 female and three male patients, with a mean age of 71.4 years (51 to 87). In the BP^- group, there were 52 female and six male patients, with a mean age of 72.1 years (53 to 88).

RESULTS

Previous treatment with bisphosphonates was positively associated with intraoperative complications (fracture; odds ratio (OR) 39.40, 95% confidence interval (CI) 2.42 to 6305.70) and one-year postoperative complications (OR 7.83, 95% CI 1.11 to 128.82), but did not achieve statistical significance for complications two years postoperatively (OR 3.45, 95% CI 0.65 to 25.28). The power was 63% for complications at one year.

CONCLUSION

Patients who are treated with bisphosphonates during the three-year period before shoulder arthroplasty have a greater risk of intraoperative and one-year postoperative complications compared with those without this previous treatment.

Intra- operative fractures in primary Total Knee Arthroplasty

BACKGROUND

Intraoperative fracture during primary Total Knee Arthroplasty (TKA) is very rare and there is little literature available which has defined the possible reasons for the occurrence of these fractures. Further, no study till date has defined the various management options available to treat these fractures. This study aims to define (1) the possible reasons for different fracture patterns occurring intraoperatively, (2) the ideal management options for each type of fracture geometry, (3) whether this intraoperative complication affects the physiotherapy protocol and long term outcomes.

METHODS

Out of 3168 primary TKA done between 2010 and 2017, 19 patients developed intraoperative fracture, whose data was evaluated retrospectively. Patients were assessed radiologically to determine the time to union and clinical outcomes were assessed using Knee Society Score.

RESULTS

Out of the 19 intraoperative fractures, 19 were in Tibia and 4 in Femur. Majority of fractures occurred during cementing and final implantation (8 cases), followed by exposure and bone preparation (6 cases) and the least during trialing (4 cases). Out of 15 Tibia fracture, 9 fractures involved the Tibial cortex which were managed with screws (4 cases), sutures and bone cement (5 cases). Stemmed tibial component was used for all Plateau type fracture patterns (6 cases). Out of 4 distal femur fractures, condylar type fracture pattern were fixed with plates and screws (3 cases) and epicondyle avulsion with screws alone (1 case). All the cases showed union (average union time 8.9 weeks) and good KSS scores which remained till their last follow-up. None of the patient developed any other complications or required revision surgery.

CONCLUSIONS

Intraoperative fracture during TKA, although rare but a significant complication which can affect the outcome, if not managed properly. We have shown methods of management for such cases, which have given excellent results.

Predictors of Intraoperative Fractures during Hemiarthroplasty for the Treatment of Fragility Hip Fractures

Background

The aim of our study was to determine the rate and preoperative predictors of intraoperative fracture (IOF) during hip hemiarthroplasty (HA) in patients who have sustained a fragility hip fracture injury.

Methods

We reviewed 626 patients who underwent HA at our institution using the National Hip Fracture Database. Various patient- and surgery-related data including demographic information, cement usage, surgeon grade, time to surgery, and operative duration were collected. The metaphyseal diaphyseal index and modified canal bone ratio were measured on preoperative radiographs. We compared patients with and without IOF with respect to all variables collected. Multivariate regression modeling was used to identify significant preoperative risk factors for IOF.

Results

There was a 7% incidence of IOF in our cohort exclusively comprising of Vancouver A fractures. The majority of these complications were treated nonoperatively (52%). There was no statistically significant difference with respect to cement usage, surgeon grade, operative duration, time to surgery, and radiographic parameters collected. Increasing age was found to be the most significant preoperative risk factor for predicting IOF (p = 0.024, overall relative risk = 1.06).

Conclusions

Our identified predictor of increasing age is nonmodifiable and illustrates the importance of meticulous surgical technique in older patients. Furthermore, its independence from fixation methods or prosthesis design as a predictor of IOF may support using an uncemented prosthesis in patients at risk from cement implantation.