The Clinical Frailty Scale is a Strong Predictor of 1-Year Mortality in Surgically Managed Hip Periprosthetic Fracture: An Analysis From a High-Volume Institution

BACKGROUND

Hip periprosthetic fractures (PPFs) after primary total hip arthroplasty are increasing with the number of primary implants and aging population. Mortality has been reported up to 34% at 1-year. The aim of this study was to evaluate the association of Clinical Frailty Scale (CFS) and 1-year mortality, complication rate, and length of stay (LOS) in surgically managed hip PPFs.

METHODS

This was a retrospective study of prospectively collected data from January 2008 to January 2021. A total of 282 surgically managed hip PPFs were identified. Mean age was 79 years (range, 42 to 106). Preoperative scores were analyzed through linear regression to identify significant association with mortality, complication and LOS. Receiver operating characteristic curve and Area Under the Curve (AUC) were generated to evaluate the quality of the models and the discriminatory ability of each clinical score. Significance was considered at P values < .05.

RESULTS

Mortality was 7.8% at 3-months and 15.7% at 1-year. Complication rate requiring surgery was 19.5% and mean LOS was 8.9 ± 7 days. The CFS was significantly associated with 3-month (odds ratio 2.23, P < .001) and 1-year mortality (odds ratio 2.01, P < .001). The receiver operating characteristic curve test for 1-year mortality showed a greater AUC for the CFS when compared with American Society for Anesthesiologists score and age-adjusted Charlson Comorbidity Index (AUC 0.80 versus 0.68 versus 0.72, respectively).

CONCLUSIONS

Frailty is a syndrome with increased risk of mortality after surgically managed PPF. The CFS can be easily assessed at the time of admission and could be considered as a strong and reliable predictor of 1-year mortality with a greater AUC than the conventionally used American Society for Anesthesiologists score.

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.

Chronic Oral Corticoteroid Use and 10-Year Incidence of Major Complications Following Total Knee Arthroplasty

INTRODUCTION

Oral corticosteroids are the primary treatment for several autoimmune conditions. The risk of long-term implant, bone health, and infectious-related complications in patients taking chronic oral corticosteroids before total knee arthroplasty (TKA) is unknown. We compared the 10-year cumulative incidence of revision, periprosthetic joint infection (PJI), fragility fracture (FF), and periprosthetic fracture (PPF) following TKA in patients who had and did not have preoperative chronic oral corticosteroid use.

METHODS

A retrospective cohort analysis was conducted using a national database. Primary TKA patients who had chronic preoperative oral corticosteroid use were identified using Current Procedural Terminology and International Classification of Disease 9 and 10 codes. Exclusion criteria included malignancy, osteoporosis treatment, trauma, and < 2-year follow-up. Primary outcomes were 10-year cumulative incidence and hazard ratios (HR) of all-cause revision (ACR), aseptic revision, PJI, FF, and PPF. A Kaplan-Meier analysis and a multivariable Cox proportional hazards model were utilized. Overall, 611,596 patients were identified, and 5,217 (0.85%) were prescribed chronic corticosteroids. There were 10,000 control patients randomly sampled for analysis.

RESULTS

Corticosteroid patients had significantly higher 10-year HR of FF [HR; 95% CI [confidence interval]; P-value (1.47; 1.34 to 1.62; P < 0.001)], ACR (1.21; 1.05 to 1.40; P = 0.009), and PJI (1.30; 1.01 to 1.69; P = 0.045) when compared to the control.

DISCUSSION

Patients prescribed preoperative chronic oral corticosteroids had higher risks of ACR, PJI, and FF within 10 years following TKA compared to patients not taking corticosteroids. This information can be used by surgeons during preoperative counseling to educate this high-risk patient population about their increased risk of postoperative complications.

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.

How Much Protection Does a Collar Provide? Assessing Risk of Early Periprosthetic Femur Fractures Following Total Hip Arthroplasty in Elderly Patients

BACKGROUND

Periprosthetic fractures (PPFs) account for approximately 25% of early revisions following total hip arthroplasty (THA). Cemented femoral fixation is associated with a lower-risk of PPF, and collared-cementless stems may reduce the risk as well. The objective of this study was to compare early-PPF rates between cemented, collared-cementless, and non-collared cementless stems in elderly patients.

METHODS

A consecutieve-series of 11,522 primary THAs performed between 2016 and 2021 at our institution in patients >65 years of age was identified. Stem types used were categorized as cemented, collared-cementless, or non-collared cementless. Patients undergoing THA who had cemented-stems were older, more commonly women, and more likely to have a posterior-approach. To reduce confounding of patient characteristics, we matched patients in the 3 stem-categories according to age, sex, and body mass index. This generated 3-groups (cemented, collared-cementless, and non-collared cementless) consisting of 936 patients per group. The mean age of these 2,808 patients was 73 years, the mean body mass index was 27, and 67% were women. Logistic regressions were used to evaluate risk-factors for early-PPF. In the entire cohort of primary THA in elderly patients, there were 85 early PPFs (0.7%) over the study period.

RESULTS

Non-collared cementless stems were associated with an increased risk of early PPF (OR: 3.11; P = .03) compared to collared-cementless stems. There were no early PPFs in the matched cemented cohort, 6 early PPFs in the matched collared-cementless cohort, and 16 early-PPFs in the matched non-collared cementless cohort (0% versus 0.64% versus 1.71%, P < .001).

CONCLUSIONS

In this large-series of patients >65 years of age undergoing primary THA, cemented stem fixation had the lowest incidence of early PPF, but collared-cementless stems had a nearly 3-fold decrease in risk for early PPF compared to non-collared cementless stems.

Osteoporosis and Total Knee Arthroplasty: Higher 5-Year Implant-Related Complications

BACKGROUND

The risk of revision surgery in patients who have osteoporosis after total knee arthroplasty (TKA) is understudied. Our aim was to compare the 5-year cumulative risk of revision surgery after TKA in patients who have preoperative osteoporosis.

METHODS

A national administrative claims database was queried for patients undergoing primary TKA from 2010 to 2021. There were 418,054 patients included, and 41,760 (10%) had osteoporosis. The 5-year incidence of revision surgery was examined for all-causes, periprosthetic fracture (PPF), aseptic loosening, and periprosthetic joint infection (PJI). A multivariable analysis was conducted using Cox proportional hazards models. Hazards ratios (HRs) were reported with 95% confidence intervals (CIs).

RESULTS

The 5-year rate of all-cause revision surgery was higher for patients who had osteoporosis (HR 1.1, 95% CI: 1.0 to 1.2), however, the highest risk of revision surgery was seen for PPF (HR 1.8, 95% CI: 1.6 to 2.1). Patients who had osteoporosis also had elevated risk of revision surgery for PJI (HR 1.2, 95% CI: 1.1 to 1.3) and aseptic loosening (HR 1.2, 95% CI: 1.1 to 1.3). Osteoporosis was independently associated with PJI and aseptic loosening at a higher rate in obese patients.

CONCLUSIONS

In unadjusted survival analysis, those who had osteoporosis have a marginally lower risk of all-cause revision surgery. However, after controlling for age, sex and comorbidities, patients who had osteoporosis have a nearly 2-fold increased risk of 5-year revision for PPF after TKA, and mildly increased risk of revision for all causes, aseptic loosening, and PJI. Obesity may also modulate this association. Future studies should determine the extent to which treatment of osteoporosis modifies these postoperative outcomes.

Mean 23-Year Outcomes of Total Hip Arthroplasty Using a Modular Femoral Stem With Metaphyseal Fixation Sleeve

BACKGROUND

Although the modular sleeve concept for femoral implants has several advantages, studies reporting on greater than 20-year outcomes are limited. This study aimed to report the mean 23-year results of total hip arthroplasty (THA) using a modular stem with metaphyseal fixation sleeve.

METHODS

This study reviewed primary THAs performed using a modular stem between October 1994 and April 1998. Of the 272 hips (221 patients) identified, 220 hips (177 patients) satisfying the minimum 20-year follow-up were included. The Harris Hip Score was used for clinical evaluation. Final hip radiographs were analyzed to evaluate the implant stability and the extent of femoral osteolysis. The mean follow-up duration was 23 years (range, 20 to 28).

RESULTS

The mean Harris Hip Score improved from 38 points (range, 26 to 67) preoperatively to 90 points (range, 71 to 100) at the final follow-up (P < .001). Femoral osteolysis was observed in 146 hips (67.1%), but 145 were located proximal to the osseo-integrated sleeve. Overall, 4 femoral revisions were performed; 2 for chronic infection, one for aseptic loosening, and one for periprosthetic femoral fracture. Of the 19 (8.6%) periprosthetic femoral fractures, the most common type was Vancouver AG (13 hips). One (0.5%) asymptomatic distal stem fracture occurred, while no complications were identified at the stem-sleeve junction. Implant survivorship free of any femoral revision was 98.3% at 23 years.

CONCLUSIONS

A THA using a modular stem with metaphyseal fixation sleeve demonstrated 98.3% stem survivorship with excellent clinical outcomes at a mean follow-up of 23 years in non-obese patients.

Intraincisional Pin Placement is Safe for Robotic-Assisted Total Knee Arthroplasty

BACKGROUND

While robotic-arm assisted total knee arthroplasty (RA-TKA) has seen a major increase in its utilization, it requires bone array pins to be fixed into the femur and tibia, which intrinsically carries a risk. As it is currently off-label with some robotic platforms to place pins intraincisional, we aimed to evaluate the safety of intraincisional pin placement during RA-TKAs.

METHODS

A prospective cohort of 2,343 patients who underwent RA-TKA at a North American Healthcare System between January 2018 and March 2022 was included. Primary outcomes included periprosthetic fracture or infection (eg, superficial or deep). Secondary outcomes included 1-year reoperation rate due to any cause. Cases were retrospectively reviewed to determine whether complications could be attributed to metaphyseal intraincisional pin placement (4.0 mm pins; two tibial and two femoral). The 90-day follow-up was 100% and the 1-year follow-up rate was 70.6% (n = 1,655).

RESULTS

The pin-site related periprosthetic fracture incidence at 90 days was 0.09% (2 out of 2,343). The 90-day infection incidence was 1.4% (superficial: 22; deep: 13). The 1-year reoperation rate was 1.8% (29 out of 1,655). The most common causes of reoperation at 1-year were deep infection (n = 14; 0.83%), superficial infection (n = 3; 0.18%), periprosthetic fracture, mechanical symptoms, instability, and hematoma (n = 2; 0.12% for each).

CONCLUSIONS

One in 1,172 patients may experience a pin-related periprosthetic fracture after RA-TKA with intraincisional bone array pin placement. There was a low 90-day infection incidence and reoperations within 1-year after RA-TKA were rare.

Postoperative Angiotensin Receptor Blocker Use is Associated With Decreased Rates of Manipulation Under Anesthesia, Arthroscopic Lysis of Adhesions, and Prosthesis-Related Complications in Patients Undergoing Total Knee Arthroplasty

BACKGROUND

The cellular mechanisms underlying excess scar tissue formation in arthrofibrosis following total knee arthroplasty (TKA) are well-described. Angiotensin receptor blockers (ARB), particularly losartan, is a commonly prescribed antihypertensive with demonstrated antifibrotic properties. This retrospective study aimed to assess the rates of 1- and 2-year postoperative complications in patients who filled prescriptions for ARBs during the 90 days after TKA.

METHODS

Patients undergoing primary TKA were selected from a large national insurance database, and the impact of ARB use after TKA on complications was assessed. Of the 1,299,106 patients who underwent TKA, 82,065 had filled at least a 90-day prescription of losartan, valsartan, or olmesartan immediately following their TKA. The rates of manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOA), aseptic loosening, periprosthetic fracture, and revision at 1 and 2 years following TKA were analyzed using multivariable logistic regressions to control for various comorbidities.

RESULTS

ARB use was associated with decreased rates of MUA (odds ratio [OR] = 0.94, 95% confidence interval (CI), 0.90 to 0.99), arthroscopy/LOA (OR = 0.86, 95% CI, 0.77 to 0.95), aseptic loosening (OR = 0.71, 95% CI, 0.61 to 0.83), periprosthetic fracture (OR = 0.58, 95% CI, 0.46 to 0.71), and revision (OR = 0.79, 95% CI, 0.74 to 0.85) 2 years after TKA.

CONCLUSIONS

ARB use throughout the 90 days after TKA is associated with a decreased risk of MUA, arthroscopy/LOA, aseptic loosening, periprosthetic fracture, and revision, demonstrating the potential protective abilities of ARBs. Prospective studies evaluating the use of ARBs in patients at risk for postoperative stiffness would be beneficial to further elucidate this association.

Three Differing Methods of Treating Intraoperative Nondisplaced Calcar Fractures Demonstrate Similar Radiographic Stem Subsidence

BACKGROUND

Several management strategies have been described to treat intraoperative calcar fractures during total hip arthroplasty (THA), including retaining the primary implant and utilizing cerclage cables (CCs) or switching the implant to one that bypasses the fracture and achieves diaphyseal fixation. However, the radiographic and clinical outcomes of these differing strategies have never been described and compared.

METHODS

We retrospectively identified 50 patients who sustained an intraoperative calcar fracture out of 9,129 primary total hip arthroplasties (0.55%) performed by one of three surgeons between 2008 and 2022. Each of the three surgeons consistently employed a distinct strategy for the management of these fractures: retention of the primary metaphyseal-engaging implant and placement of CCs; exchange to a modular, tapered-fluted stem (MTF); or exchange to a fully-coated, diaphyseal-engaging stem (FC). Stem subsidence was then evaluated on standing anteroposterior pelvis radiographs at three months and one year postoperatively. Postoperative medical and surgical complication rates were evaluated.

RESULTS

A total of fifteen patients were treated with CC, 15 with MTF, and 20 with FC. At three-month follow-up, mean stem subsidence was 0.43 ± 0.08 mm, 1.47 ± 0.36 mm, and 0.68 ± 0.39 mm for CC, MTF, and FC cohorts, respectively (P = .323). At one-year, mean stem subsidence was 0.70 ± 0.08 mm, 1.74 ± 0.69 mm, and 1.88 ± 0.90 mm for the CC, MTF, and FC cohorts, respectively (P = .485). Medical complications included 2 venous thromboembolic events (4%) within 90 days of surgery. There were 6 reoperations (12%); 3 (6%) for acute periprosthetic joint infection (all within the FC cohort); 2 (4%) for postoperative periprosthetic fractures (one fracture distal to the stem in the FC cohort and one fracture at the level of the stem in the MTF cohort), and 1 (2%) closed reduction for instability (within the CC cohort).

CONCLUSIONS

The three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence; however, the risk of reoperation was much higher than expected.

Mechanical loading of bone-anchored implants during functional performance tests in service members with transfemoral limb loss

Introduction

For individuals with limb loss, bone-anchored implants create a direct structural and functional connection to a terminal prosthesis. Here, we characterized the mechanical loads distal to the abutment during several functional performance tests in Service members with transfemoral (TF) limb loss, to expand on prior work evaluating more steady-state ambulation on level ground or slopes/stairs.

Methods

Two males with unilateral TF limb loss and two males with bilateral TF limb loss participated after two-stage osseointegration (24 and 12 months, respectively). Tri-directional forces and moments were wirelessly recorded through a sensor, fit distal to the abutment, during six functional tests: Timed Up and Go (TUG), Four Square Step Test (FSST), Six Minute Walk Test (6MWT), Edgren Side-Step Test (SST), T-Test (TTEST), and Illinois Agility Test (IAT). Additionally, participants performed a straight-line gait evaluation on a 15 m level walkway at a self-selected speed (0.93-1.24 m/s). Peak values for each component of force and moment were extracted from all six functional tests; percent differences compared each peak with respect to the corresponding mean peak in straight-line walking.

Results

Peak mechanical loads were largest during non-steady state components of the functional tests (e.g., side-stepping during SST or TTEST, standing up from the ground during IAT). Relative to walking, peak forces during functional tests were larger by up to 143% (anterior-posterior), 181% (medial-lateral), and 110% (axial); peak moments were larger by up to 108% (flexion-extension), 50% (ab/adduction), and 211% (internal/external rotation).

Conclusions

A more comprehensive understanding of the mechanical loads applied to bone-anchored implants during a variety of activities is critical to maximize implant survivability and long-term outcomes, particularly for Service members who are generally young at time of injury and return to active lifestyles.

The Association Between Oral Bone Mineral Density-Reducing Medications and the Risk of 2-Year Implant-Related Complications Following Total Knee Arthroplasty

BACKGROUND

Certain medications interfere with the bone remodeling process and may potentially increase the risk of complications after total knee arthroplasty (TKA). As patients undergoing TKA may be taking these bone mineral density (BMD)-reducing medications, it is unclear as to whether and which medications impact TKA outcomes. Therefore, the purpose of this study was to observe the impact of various BMD-reducing medications on 2-year implant-related complications following TKA.

METHODS

A retrospective analysis of patients undergoing primary TKA was conducted using a national administrative claims database. Patients were identified if they were taking any known BMD-reducing medication and were compared to control patients. To control for confounders associated with taking multiple agents, multivariable logistic regression analyses were conducted for each 2-year outcome (all-cause revision, loosening-indicated revision, and periprosthetic fracture--indicated revision), with the output recorded as odds ratios (ORs).

RESULTS

In our study, 502,927 of 1,276,209 TKA patients (39.4%) were taking at least one BMD-reducing medication perioperatively. On multivariable analysis, medications associated with a higher likelihood of 2-year all-cause revision included first- and second-generation antipsychotics (SGAs) (OR: 1.42 and 1.26, respectively), selective serotonin reuptake inhibitors (SSRIs) (OR: 1.14), glucocorticoids (1.13), and proton pump inhibitors (PPIs) (OR: 1.23) (P < .05 for all). Medications associated with a higher likelihood of 2-year periprosthetic fracture included SGAs (OR: 1.51), SSRIs (OR: 1.27), aromatase inhibitors (OR: 1.29), and PPIs (OR: 1.42) (P < .05 for all).

CONCLUSIONS

Of the drug classes observed, the utilization of perioperative PPIs, SSRIs, glucocorticoids, first-generation antipsychotics, and SGAs was associated with the highest odds of all-cause revision. Our findings suggest a relationship between these medications and BMD-related complications; however, further studies should seek to determine the causality of these relationships.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Increased Rates of Late Periprosthetic Fractures in Larger Hydroxyapatite-Coated Cementless Stems: Are Collared Stems a Better Alternative for Total Hip Arthroplasty?

BACKGROUND

Cementless hip stems are widely used for total hip arthroplasty (THA) and have demonstrated excellent survivorship. This study aimed to investigate the effects of stem size and calcar collars on rates of revision due to periprosthetic fracture.

METHODS

All primary THA procedures recorded by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from September 1999 to December 2021 for a diagnosis of osteoarthritis using a single cementless hip stem with modern bearings were included. The primary outcome measure was revision due to periprosthetic fracture. Stems were divided into 2 groups for comparison, large (size 14 to 20) and small-medium (6 to 13). A subanalysis was performed for collared stems. A total of 59,518 primary THA procedures were included.

RESULTS

The cumulative percent revision for periprosthetic fracture was significantly higher for large stems compared to small-medium stems (hazard ratio [HR] = 1.57 [95% confidence interval {CI} 1.18, 2.09] P = .002). Furthermore, collared stems had significantly lower revision rates due to late periprosthetic fracture compared to collarless variants (2 week + HR = 4.55 [95% CI 3.23, 6.42], P < .001). Large collarless stems were found to have greater revision rates due to fracture compared to small-medium collarless stems (HR = 1.55 [95% CI 1.13, 2.12] P = .006), but no difference was found between collared groups (HR = 1.37 [95% CI 0.68, 2.78] P = .382).

CONCLUSION

Large cementless hip stems have a higher rate of revision due to periprosthetic fracture compared to small-medium stems. Using a collared stem reduces the rate of periprosthetic fracture.

Prehabilitation in a Periprosthetic Fracture of the Femur: A Case Report

Periprosthetic fractures (PPF) are related to orthopaedic implants like internal fixators, replacement devices, etc. In this case report, we discussed a 55-year-old male patient who came to our tertiary care hospital with complaints of pain and swelling over the left hip for six months. After radiological investigations, he was diagnosed with a left PPF of the femur with posterior dislocation. He was referred to the musculoskeletal physiotherapy department for in-patient rehabilitation before surgery. He received strengthening exercises for lower limb, back, and abdominal muscles, pain management, gait training, etc. for two weeks before his decided surgery date. The patient showed improved strength and maintained his range. There were an improved Visual Analogue Scale (VAS) score and a Lower Extremity Functional Scale (LEFS) score, which signified a reduction in pain and improved functional independence due to enhanced lower limb function, respectively.

Revision surgery for periprosthetic fracture of distal femur after endoprosthetic replacement of knee joint following resection of osteosarcoma

Purpose

Periprosthetic fracture (PPF) is one of the severe complications in patients with osteosarcoma and carries the risk of limb loss. This study describes the characteristics, treatment strategies, and outcomes of this complication.

Methods

Patients were consecutively included who were treated at our institution between 2016 and 2020 with a PPF of distal femur. The treatment strategies included two types: 1) open reduction and internal fixation with plates and screws and 2) replacement with long-stem endoprosthesis and reinforcement with wire rope if necessary.

Results

A total of 11 patients (mean age 12.2 years (9-14)) were included, and the mean follow-up period was 36.5 (21-54) months. Most fractures were caused by direct or indirect trauma (n = 8), and others (n = 3) underwent PPF without obvious cause. The first type of treatment was performed on four patients, and the second type was performed on seven patients. The mean Musculoskeletal Tumor Society (MSTS) score was 20 (17-23). All patients recovered from the complication, and limb preservation could be achieved.

Conclusion

PPF is a big challenge for musculoskeletal oncologists, particularly in younger patients. Additionally, PPF poses a challenge for orthopedic surgeons, as limb preservation should be an important goal. Hence, internal fixation with plates and endoprosthetic replacement are optional treatment strategies based on fracture type and patient needs.

Sex-Specific Implant Fixation Can Reduce Revision Rates in Total Hip Arthroplasty: Evidence From the Swiss National Joint Registry

BACKGROUND

Patient's sex is considered a risk factor for revision following primary total hip arthroplasty (THA), but sex-specific treatment guidelines are lacking. The purpose was to assess sex-specificity of risk factors for periprosthetic femoral fractures (PFFs) and aseptic stem loosening (ASL) in a nationwide register study.

METHODS

All uncemented and hybrid THAs for hip osteoarthritis registered in the Swiss National Joint Registry were considered. 86,423 THAs were analyzed. Comparable THA subsets for both sexes were obtained through propensity score matching (1:1). A sex-specific analysis of risk factors for early PFF or ASL was performed using recursive partitioning analyses.

RESULTS

In women, PFFs were most significantly associated with uncemented THA fixation (P < .0001) and age (P < .01, threshold: 70.5 years). The ASLs were solely associated with patient age of <65 years (P = .023). In men, PFFs were associated exclusively with an American Society of Anesthesiologists (ASA) score >2 (P = .026). The ASLs were not correlated to any of the potential risk factors analyzed. A mathematical simulation indicated that avoiding uncemented THA fixation in women ≥70.5 years of age decreased the number of revisions within the observational period by 21% in this subset and by 4.9% in the entire patient population.

CONCLUSION

Uncemented THA should be avoided in women >70.5 years due to the increased risk of early PFF, while the mode of stem fixation did not influence revision risk in men. A sex-specific regimen for THA fixation has the potential to markedly reduce early THA revision rates.

Bisphosphonate Use May be Associated With an Increased Risk of Periprosthetic Hip Fracture

BACKGROUND

Osteoporosis is common among patients undergoing primary total hip arthroplasty (THA). This study aimed to evaluate the effect of bisphosphonate treatment on osteoporotic patients undergoing primary THA.

METHODS

Using a national database, 30,137 patients who had osteoporosis before primary elective THA were identified during 2010 to 2020. Patients undergoing nonelective THA and those using corticosteroids or other medications for osteoporosis were excluded. Bisphosphonate users and bisphosphonate naïve patients were matched 1:1 based on age, sex, Elixhauser comorbidity index, and a history of obesity, rheumatoid arthritis, tobacco use, and alcohol abuse. Kaplan-Meier and multivariate analyses were used to compare 2-year outcomes between groups.

RESULTS

Among matched cohorts of 9,844 patients undergoing primary THA, bisphosphonate use was associated with a significantly higher 2-year rate of periprosthetic fracture (odds ratio 1.29, 95% confidence interval 1.04 to 1.61, P = .022). There was a trend toward increased risk of any revision with bisphosphonate use (odds ratio 1.19, confidence interval 1.00 to 1.41, P = .056). Rates of infection, aseptic loosening, dislocation, and mortality were not statistically different between bisphosphonate users and bisphosphonate-naïve patients.

CONCLUSION

In osteoporotic patients, bisphosphonate use before primary THA is an independent risk factor for periprosthetic fracture. Additional longer-term data are needed to determine the underlying mechanism for this association and identify preventative measures.

Patella Fracture After Total Knee Arthroplasty: A Review

The management and underlying causes of patellar periprosthetic fractures (PPF) after total knee arthroplasty (TKA) constitute an issue of growing importance given the rising frequency of these procedures. Patella periprosthetic fractures, though relatively rare, pose significant challenges and are a frequent indication for revision surgeries. Despite a decrease in overall incidence, PPFs remain the second most common type of periprosthetic fractures after TKA. Several factors have been identified and associated with patient-specific factors, surgical technique errors, and implant-related causes. Currently extensor apparatus integrity, bone stock, and component loosening are the major concerns and indications for the selective treatment approach. In this study, a thorough review of the existing literature was performed summarizing the epidemiology, clinical manifestation, treatment approach, and functional outcome of PPF. This review aims to underline the significance of such predisposing factors, point out the severity of PPF, and offer insights into the optimal intra- and post-operative management of the patella.

Experience of an Anatomic Femoral Stem in a United Kingdom Center - Excellent Survivorship and Negligible Periprosthetic Fracture Rates at Mean 12 Years Following Primary Total Hip Arthroplasty

BACKGROUND

As the clinical burden of periprosthetic fractures (PPFs) continues to increase, it has been suggested that the use of anatomical femoral stems may help reduce PPF risk. The primary aim of this study was to determine the survivorship and PPF rate of an anatomical femoral stem in a single center at minimum 10-year follow-up.

METHODS

A total of 1,000 consecutive total hip arthroplasties (THAs) performed using an anatomical femoral stem were identified from a prospectively collected arthroplasty database. Patient radiographs were reviewed finally at a mean of 12 years (range, 10 to 16 years) following surgery to identify any revision surgery, dislocations or PPFs. Mean patient age at surgery was 69 years (range, 24 to 93). There were 634 women (63%). Osteoarthritis was the operative indication in 946 patients (95%).

RESULTS

All-cause THA survivorship was 99.1% (95% confidence interval (CI), 99.0-99.3%) at 10 years and 97.9% (CI, 97.8 - 98.0%) at 15 years. Stem survivorship at 10 years was 99.6% (CI, 99.5-99.7%) and at 15 years was 98.2% (CI, 98.1-98.3%). The 15-year stem survival for aseptic loosening was 100% with no cases of significant lysis found (lucent line >2mm). Implant survivorship was not significantly impacted by patient sex (P = .65), body mass index (P = .49), deprivation level (P = .284), operative indication (P = .33), or American Society of Anesthesiologists class (P = .374). There were 3 PPFs identified (0.3%) at mean 12-year follow-up and 15 dislocations (1.5%).

CONCLUSION

This anatomical femoral stem demonstrated excellent survivorship and negligible PPF rates at mean 12-year follow-up following primary THA.

Strikingly High Rates of Periprosthetic Joint Infection Following Revision Surgery for Periprosthetic Fractures Regardless of Surgery Timing

BACKGROUND

Periprosthetic fractures following total hip arthroplasty (THA) often occur in the early postoperative period. Recent data has indicated that early revisions are associated with higher complication rates, particularly periprosthetic joint infection (PJI). The purpose of this study was to assess the effect of timing of periprosthetic fracture surgery on complication rates. We hypothesized that complication rates would be significantly higher in revision surgeries performed within 3 months of the index THA.

METHODS

The Medicare Part A claims database was queried from 2010 to 2017 to identify patients who underwent surgery for a periprosthetic fracture following primary THA. Patients were divided based on time between index and revision surgeries: <1, 1 to 2, 2 to 3, 3 to 6, 6 to 9, 9 to 12, and >12 months. Complication rates were compared between groups using multivariate analyses to adjust for demographics, comorbidities, and types of revision surgery.

RESULTS

Of 492,340 THAs identified, 4,368 (0.9%) had a subsequent periprosthetic fracture requiring surgery: 1,725 (39.4%) at <1 month, 693 (15.9%) at 1 to 2 months, 202 (4.6%) at 2 to 3 months, 250 (5.7%) at 3 to 6 months, 134 (3.1%) at 6 to 9 months, 85 (19.4%) at 9 to12 months, and 1,279 (29.3%) at >12 months. The risk of PJI was 11.0% in the <1 month group, 11.1% at 1 to 2 months, 7.9% at 2 to 3 months, 6.8% at 3 to 6 months, 8.2% at 6 to 9 months, 9.4% at 9 to 12 months, and 8.5% at >12 months (P = .12). Adjusting for confounding factors, risk of PJI following periprosthetic fracture surgery was similar regardless of timing (P > .05). Rates of subsequent dislocation and aseptic loosening were also similar regardless of timing.

CONCLUSIONS

The risk of PJI following repeat surgery for a periprosthetic fracture was strikingly high regardless of timing (6.8 to 11.1%), underscoring the high-risk of complications.

Inflammatory bowel disease patients undergoing total hip arthroplasty have higher odds of implant-related complications

PURPOSE

This study evaluates whether IBD patients are at increased risk of implant-related complications after THA.

MATERIALS AND METHODS

A retrospective study from 01 January 2010 to 31 October 31 2020 using an administrative claims database was performed. IBD patients undergoing THA (n = 11,025), without corticosteroid treatment, were propensity score matched to controls in a 1:5 ratio (n = 55,121) based on age, sex, and the Charlson Comorbidity Index (CCI). Outcomes evaluated included periprosthetic fracture, aseptic loosening, prosthetic joint infection, and THA revision within 2 years of index procedure. Chi-square analyses were used to compare the matched cohorts. The association of IBD and implant-related complications was evaluated using logistical regression to calculate odds ratios (ORs), 95% confidence intervals (95% CIs), and p-values. A p-value < 0.001 was used as the significance threshold.

RESULTS

Patients with IBD had a greater incidence and odds of total implant complications (7.03% vs. 3.98%; OR 1.76; p < 0.001) compared with matched controls. IBD patients had significantly higher incidence and odds of developing periprosthetic fracture (0.50% vs. 0.20%; OR 2.46; p < 0.001), THA revisions (2.21% vs. 1.17%; OR 1.91; p < 0.001), aseptic loosening (1.45% vs. 0.84%; OR 1.75; p < 0.001), and prosthetic joint infection (2.87% vs. 1.77%; OR 1.64; p < 0.001).

CONCLUSIONS

Patients with IBD who underwent primary THA had a significantly higher risk of implant-related complications compared to matched controls. Providers should use this study to appropriately assess post-complication risk factors for their patients with IBD.

Initiation of Bisphosphonates Prior to Total Joint Arthroplasty Does Not Lower Periprosthetic Fracture Risk

BACKGROUND

Many patients are diagnosed with osteoporosis shortly prior to scheduling total joint arthroplasty (TJA). The purpose of this study was to determine if initiation of bisphosphonates prior to TJA decreased the risks of periprosthetic fractures (PPFx).

METHODS

A national database was used to identify all patients diagnosed with osteoporosis prior to primary TJA. Patients who had osteoporosis without preoperative bisphosphonate use were designated as our control group. Patients on preoperative bisphosphonates were stratified based on duration and timing of bisphosphonate use: long-term preoperative users (initiation 3 to 5 years preoperatively), intermediate-term preoperative users (initiation 1 to 3 years preoperatively), and short-term preoperative users (initiation 0 to 1 year preoperatively). Rates of PPFx at 90-day and 2-year follow-up were compared between groups.

RESULTS

In patients undergoing primary total hip arthroplasty, there was no difference in PPFx rate between our control group and preoperative bisphosphonate users of all durations at 90-day (P = .12) and 2-year follow-up (P = .22). In patients undergoing primary total knee arthroplasty, there was no difference in PPFx rate between our control group and preoperative bisphosphonate users of all durations at 90-day (P = .76) and 2-year follow-up (P = .39).

CONCLUSIONS

In patients undergoing primary TJA, preoperative bisphosphonate users did not have a decreased PPFx rate compared to our control group at 90-day and 2-year follow-up. Our findings suggest that preoperative bisphosphonate use, regardless of the duration of treatment, does not confer protective benefits against PPFx in patients undergoing TJA.

LEVEL OF EVIDENCE

Prognostic Level III.

A Comparison of the Periprosthetic Fracture Rate of Cemented and Cementless Total Knee Arthroplasties: An Analysis of Data From the National Joint Registry

BACKGROUND

Periprosthetic fractures are serious complications of knee arthroplasty often requiring complex surgery. There is concern of increased periprosthetic fracture risk with cementless components given the reliance on interference fit for primary stability. It is unknown how the periprosthetic fracture risk compares between cemented and cementless total knee arthroplasties (TKAs).

METHODS

A total of 22,477 cemented and 22,477 cementless TKAs from the National Joint Registry and Hospital Episodes Statistics database were propensity score matched on patient and surgical factors. Cumulative periprosthetic fracture rates were calculated using Kaplan-Meier analyses and compared with Cox regressions. Subgroup analyses were performed in different age, body mass index, and sex groups.

RESULTS

The 3-month fracture rate in the cemented and cementless TKA groups were 0.02% and 0.04%, respectively. At 10 years, the cumulative fracture rate after cemented TKA was 1.2%, and after cementless was 1.4%. During the study period, there were no significant differences in fracture rates between cemented and cementless TKAs with a hazards ratio 1.14 (confidence interval 0.94 to 1.37, P = .20) at 10 years postoperatively. There were no significant differences in fracture rates between fixation types on subgroup analyses of sex, body mass index, and age groups. Female sex was a risk factor for fracture in both cemented (odds ratio 2.35, P < .001) and cementless TKAs (odds ratio 2.97, P < .001).

CONCLUSIONS

The periprosthetic fracture rates following cemented and cementless TKA surgery are low being approximately 1.2% and 1.4%, respectively at 10 years. There were no significant differences in periprosthetic fracture rates requiring readmission between cemented and cementless TKAs.

LEVEL OF EVIDENCE

III.

Biomechanics of PHILOS plates in Vancouver B1 periprosthetic femoral fracture

Objective: To investigate the clinical efficacy of PHILOS plates in the treatment of Vancouver B1 periprosthetic femoral fracture (PFF) and to validate its biomechanical reliability via finite element analysis and mechanical testing on the Synbone femoral models. Methods: Ten males and eight females with Vancouver B1 PFF who underwent PHILOS plate fixation between September 2017 and January 2022 were selected. The average age was 72.61 ± 8.19 years, with a range of 57-86 years old. X-ray films were taken to assess the fracture healing situation around the femoral prosthesis as well as the position of the PHILOS plates and femoral prosthesis. Two different plates (the PHILOS plate and the Cable GTR plate) were used for fixation, and the differences in biomechanical stability of the two fixation methods were compared using finite element analysis and mechanical testing on the Synbone femoral models to validate the biomechanical dependability of the PHILOS plate. Results: All 18 cases were followed for at least 1 year, as a result. The average period of follow-up was 17 months, ranging from 12 to 36 months. At the most recent follow-up, Harris scores for the hip joints of patients ranged from 82 to 89, with an average score of 86. The X-rays revealed that all fractures surrounding the femoral prosthesis had healed and that there was no looseness in the femoral prosthesis. None of the PHILOS license plates had expired. All patients were able to perform full-load walking, and pain and claudication in affected limbs were significantly reduced. Finite element analysis and mechanical testing of the Synbone femoral model revealed that the fixation effect of the PHILOS group was superior to that of the Cable group; consequently, PHILOS plates can be used to effectively fix fractures around the proximal femoral prosthesis. Conclusion: PHILOS plates are initially used in the treatment of Vancouver B1 PFF, which may be a good choice due to their simpler operation, lower medical costs, and satisfactory clinical efficacy.

Stem size and stem alignment affects periprosthetic fracture risk and primary stability in cementless total hip arthroplasty

The ideal stem size and stem position is important for the success of total hip arthroplasty, since it can affect early implant loosening and periprosthetic fractures (PPF). This study aimed to investigate how small deviations from the ideal stem size and position influences the PPF risk and primary stability. Six experienced surgeons performed preoperative templating based on which the benchmark size for each femur was determined. Consecutive implantations were performed in six cadaveric femur pairs-one side was implanted with an undersized stem followed by the benchmark size and the contralateral side with a benchmark size followed by an oversized stem (Corail, Depuy Synthes). Moreover, three different alignments (six varus, six neutral, six valgus-undersized) were compared using 18 femurs. Cortical strains during broaching and implantation were measured, and laser scans were used to determine final stem position. All specimens underwent dynamic loading. Primary stability was estimated from stem subsidence and pull-out forces. Templated stem size varied between surgeons (±1 size; p = 0.005). Undersizing increased stem subsidence by 320% (p < 0.001). Oversized stems exhibited 52% higher pull-out forces (p = 0.001) and 240% higher cortical strains (p = 0.056). Cortex strains increased with varus alignment (R2  = 0.356, p = 0.011) while primary stability decreased with valgus stem alignment (p = 0.043). Surgeons should be aware that small deviations from the ideal stem size and malalignments of the stem can significantly alter the mechanical situation and affect the success of their surgery.

A comparison of mortality rates following revision hip arthroplasty for periprosthetic fracture, infection or aseptic loosening

BACKGROUND

Mortality following revision hip surgery for periprosthetic fracture (PPF) is comparable to neck of femur fractures. Our institution provides a regional "PPF Service". The aim of this study was to determine the time to surgery and mortality rate for PPF, compared to revision for infection or aseptic loosening.

METHODS

Revision arthroplasty procedures performed for PPF, infection or aseptic loosening between January 2014 and December 2015 were identified. Comparisons were made between the 3 groups for baseline demographics, admission to higher-level care, length of stay, complications and mortality.

RESULTS

There were 37 PPF, 71 infected and 221 aseptic revisions. PPF had a higher proportion of females (65% vs. 39% in infection and 53% in aseptic; p = 0.031) and grade 3 and 4 ASA patients (p = 0.006). Median time to surgery for PPF was 8 days (95% CI, 6-16). Single-stage procedures were performed in 84% of PPF, 42% of infections and 99% of aseptic revisions (p < 0.001). 19% of PPF revisions required HDU admission, 1% in the aseptic group and none in the infection group. Median length of stay was significantly different (PPF 10; infection 14; aseptic 8 days (p < 0.001). The 1-year mortality rate for PPF was 0%, 2.8% for infection and 0.9% in the aseptic group (p = 0.342).

CONCLUSIONS

Despite the PPF group having higher ASA grades and more HDU admissions, our 1-year mortality rate was 0% and not significantly different to infection or aseptic loosening. Our low complication and 1-year mortality rate is encouraging and supports the safety of a regional "Periprosthetic Fracture Service".

Rectangular Taper Stem Designs Are Associated With a Higher Risk for Periprosthstic Femoral Fractures After Cementless Total Hip Arthroplasty

BACKGROUND

Periprosthetic femoral fractures (PFFs) remain a major concern following cementless total hip arthroplasty (THA). This study aimed to evaluate the association between different types of cementless tapered stems and the risk of postoperative PFF.

METHODS

A retrospective review of primary THAs performed at a single center from January 2011 to December 2018 included 3,315 hips (2,326 patients). Cementless stems were classified according to their design. The incidence of PFF was compared between flat taper porous-coated stems (type A), rectangular taper grit-blasted stems (type B1), and quadrangular taper hydroxyapatite-coated stems (type B2). Multivariate regression analyses were performed to identify independent factors related to PFF. The mean follow-up duration was 61 months (range, 12 to 139). Overall, 45 (1.4%) postoperative PFFs occurred.

RESULTS

The incidence of PFF was significantly higher in type B1 stems than in type A and type B2 stems (1.8 versus 0.7 versus 0.7%; P = .022). Additionally, more surgical treatments (1.7 versus 0.5 versus 0.7%; P = .013) and femoral revisions (1.2 versus 0.2 versus 0%; P = .004) were required for PFF in type B1 stems. After controlling for confounding variables, older age, diagnosis of hip fracture, and use of type B1 stems were significant factors associated with PFF.

CONCLUSION

Type B1 rectangular taper stems were found to have higher risks for postoperative PFF and PFF requiring surgical management than type A and type B2 stems in THA. Femoral stem geometry should be considered when planning for cementless THA in elderly patients who have compromised bone quality.

Periprosthetic fractures after shoulder arthroplasty: a systematic review

Purpose

The goal of this study was to review available literature on periprosthetic shoulder fractures to evaluate epidemiology, risk factors and support clinical decision-making regarding diagnostics, preoperative planning, and treatment options.

Methods

Two authors cross-checked the PubMed and Web of Science medical databases. The inclusion criteria were as follows: original human studies published in English, with the timeframe not limited, and the following keywords were used: 'periprosthetic shoulder fracture,' 'total shoulder arthroplasty periprosthetic fractures,' 'total shoulder arthroplasty fracture,' and 'total shoulder replacement periprosthetic fracture.' Seventy articles were included in the review. All articles were retrieved using the aforementioned criteria.

Results

The fracture rate associated with total shoulder arthroplasty varied between 0 and 47.6%. Risk factors for periprosthetic fractures were female gender, body mass index < 25 kg/m2, smoking, rheumatoid arthritis, and Parkinson's disease. The most commonly used classification is the Wright and Coefield classification. Periprosthetic fractures can be treated both, conservatively and operatively.

Conclusion

Periprosthetic fracture frequency after shoulder arthroplasty ranges from 0 to 47.6%. The most common location of the fracture is the humerus and most commonly occurs intraoperatively. The most important factor influencing treatment is stem stability. Fractures with stem instability require revision arthroplasty with stem replacement. Fractures with a stable stem depending on the location, displacement and bone stock quality can be treated both conservatively and operatively. For internal fixation plates with cables and screws are most commonly used.

Femoral Head Length Impact on Outcomes Following Total Hip Arthroplasty in 36 Millimeter Cobalt Chrome-on-Highly Crosslinked Polyethylene Articulations

BACKGROUND

Despite concerns for corrosion, dislocation, and periprosthetic femur fractures, minimal literature has investigated the effect of adjusting femoral head length on outcomes after primary total hip arthroplasty (THA). Therefore, we aimed to investigate the effect of femoral head length on the risk of any revision and reoperation following cobalt chromium (CoCr)-on-highly crosslinked polyethylene (HXLPE) THAs.

METHODS

Between 2004 and 2018, we identified 1,187 primary THAs with CoCr-on-HXLPE articulations using our institutional total joint registry. The mean age at THA was 71 years (range, 19-97), 40% were women, and mean body mass index was 30 (range, 10-68). All THAs using 36 mm diameter femoral heads were included. Neutral (0 mm), positive, or negative femoral head lengths were used in 42, 31, and 27% of the THAs, respectively. Kaplan-Meier survivorship was assessed. The mean follow-up was 7 years (range, 2-16).

RESULTS

The 10-year survivorships free of any revision or reoperation were 94 and 92%, respectively. A total of 47 revisions were performed, including periprosthetic femur fracture (17), periprosthetic joint infection (8), dislocation (7), aseptic loosening of either component (6), corrosion (4), and other (5). Nonrevision reoperations included wound revision (11), open reduction and internal fixation of periprosthetic femur fracture (4), and abductor repair (2). Multivariable analyses found no significant associations between femoral head length and revision or reoperation.

CONCLUSION

Altering femoral head lengths in 36 mm CoCr-on-HXLPE THAs did not affect outcomes. Surgeons should select femoral head lengths that optimize hip stability and center of rotation.

LEVEL OF EVIDENCE

III.

The Association of Prior Fragility Fractures on 8-Year Periprosthetic Fracture Risk Following Total Hip Arthroplasty

BACKGROUND

Fragility fractures are often the initial clinical presentation of osteoporosis. Patients who have a history of fragility fractures undergoing total hip arthroplasty (THA) have an increased risk of 2-year postoperative complications. However, the association of recent fragility fractures with complications beyond 2 years following THA remains unknown. The purpose of this study was to characterize the association of prior fragility fractures with 8-year risks of revision THA, periprosthetic fracture (PPF), and secondary fragility fracture.

METHODS

Patients aged 50 years and more who underwent THA for osteoarthritis were identified in a large national database. Patients were stratified based on whether they sustained a fragility fracture within 3 years prior to THA. There were 18,529 patients who had a prior fragility fracture and 408,753 who did not have a prior fragility fracture. Demographics and comorbidities were collected. Kaplan-Meier and Cox Proportional Hazards analyses were used to observe the cumulative incidences of all-cause revision, PPF, and secondary fragility fracture within 8 years of index surgery.

RESULTS

Patients who had recent fragility fracture had significantly higher risks of revision THA (Hazard Ratio [HR] 1.7; P < .001), PPF (HR 2.2; P < .001), and secondary fragility fracture (HR 4.9; P < .001).

CONCLUSION

Prior fragility fracture was shown to be a significant risk factor for revision THA, PPF, and secondary fragility fracture within 8 years of THA. Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize these complications.

Subsidence in Centraliser Sign: A Novel Tool to Help Predict Early Subsidence in Periprosthetic Femoral Fractures Around Polished Tapered Stems Treated With Internal Fixation

Background When treating periprosthetic femoral fractures (PPF) around polished taper slip stems (PTS), determining which patients can be successfully treated with internal fixation can be challenging. We have described the subsidence-in-centraliser (SINC) sign as a radiographic feature of PPF around PTS stems. We hypothesise that a positive SINC sign can help predict a poorer outcome for the fixation of these fractures. Patients and methods Retrospective identification of PPFs around cemented PTS with an appreciable centraliser on radiographs was conducted at a single centre. A positive SINC sign was defined as a post-injury radiograph demonstrating >50% reduction in the radiographic lucency representing the stem centraliser when compared to pre-injury films or complete obliteration of distal lucency when no pre-injury film was available. The primary outcome was the rate of subsequent stem subsidence on follow-up radiographs comparing SINC-positive and SINC-negative fractures, which were managed with open reduction and internal fixation (ORIF). Results Fifty-four patients were included in the analysis. The mean age was 76.8 years, and the mean follow-up for all patients was 12.7 months. Thirty-five fractures were deemed SINC-positive, and 19 were SINC-negative. 17/17 (100%) SINC-positive fractures managed with fixation underwent further subsidence (mean 5.4 mm, SD 2.8). A positive SINC sign demonstrated a sensitivity of 90.5% and specificity of 100% for subsequent stem subsidence in fractures treated without revision. SINC positive fractures underwent significantly more subsidence compared with SINC negative fractures when fixed (5.4 mm vs. 0.28 mm, U = 6.50, p<0.001) at a mean follow-up of 12.7 months. The SINC sign demonstrated strong inter- (k=0.96) and intra-rater (k=0.86) reliability. Conclusion The SINC sign can serve as a useful adjunct in the decision to fix or revise PPF around PTS. A positive SINC sign may represent a cement mantle that cannot be reconstituted anatomically, leading to subsidence after treatment with ORIF.

Can Selected Use of Cemented and Uncemented Femoral Components in a Broad Population Produce Comparable Results Following Primary Total Hip Arthroplasty for Osteoarthritis?

INTRODUCTION

Registry data have demonstrated lower rates of revision and periprosthetic fracture in select cohorts with cemented femoral fixation at primary total hip arthroplasty (THA). Whether this is true of all component designs is not known. We hypothesized that selected use of ream-and-broach, triple-tapered uncemented stem designs may provide comparable results to cemented stems.

METHODS

From 2000 to 2018, 5,809 primary THAs were performed with either a cemented (1,304) or ream-and-broach triple-tapered uncemented stem (4,505). Implant choice was at surgeon discretion. The cemented group was older, more often women, and had slightly lower body mass index. A subgroup analysis was performed on patients ≥75-years of age. Statistical weighting accounted for baseline cohort differences.

RESULTS

At 10 years, there was a trend toward higher all-cause revision (Hazards ratio (HR) 1.6, P=0.053) and higher all-cause reoperation (HR 1.6, P=0.02) in the cemented fixation cohort. The cemented fixation group had fewer intraoperative periprosthetic fractures (HR 0.21, P<0.001), but no difference in postoperative fractures (HR 0.99, P=0.96). The same was true in patients ≥75-years. In the ≥75-years subgroup, there was no difference in revision or reoperation at 10 years.

CONCLUSION

Compared to cemented stems, the use of ream-and-broach triple-tapered uncemented stems in select patients, including those ≥75-years, was associated with more intraoperative fractures, but no difference in 10-year implant survivorship. These findings are different than some registry data and suggest that specific uncemented components, implanted in selected patients by experienced surgeons, can perform as well as cemented implants in a broad patient population.

The Association of Postoperative Osteoporosis Therapy With Periprosthetic Fracture Risk in Patients Undergoing Arthroplasty for Femoral Neck Fractures

BACKGROUND

Displaced femoral neck fractures in older adults are generally treated with hip arthroplasty. One concern following hip arthroplasty is the risk for periprosthetic fractures (PPFs). Most patients who have hip fractures are candidates for antiosteoporotic therapy, but the impact of this treatment on PPFs is unknown. Therefore, the primary objective of this study was to evaluate whether patients treated with antiosteoporotic medical therapy had lower odds of PPFs following arthroplasty for hip fracture.

METHODS

Patients at least 65 years old who underwent hip arthroplasty for femoral neck fractures from 2010 to 2020 were identified in a national database. Patients were stratified based on whether they initiated antiosteoporotic therapy within 1 year of hip arthroplasty. Minimum follow-up was 1 year, and maximum follow-up was 10.6 years. The primary endpoint was cumulative incidence of PPF as determined using Kaplan-Meier and Cox proportional hazards regression analyses. Overall, 2,026 patients who underwent arthroplasty for femoral neck fracture received antiosteoporotic medications within 1 year following surgery (mean follow up 4.8 years; range 1.0 to 10.6 years) and 33,639 patients did not (mean follow up 4.1 years; range 1.1 to 10.3 years).

RESULTS

The 10-year cumulative incidence of PPF for patients treated for osteoporosis was 3.88% compared to 5.92% for those who were untreated (P < .001). Adjusting for covariates, patients who received osteoporosis treatment had a significantly lower risk for PPF than those who were untreated (hazard ratio (HR): 0.663; 95% confidence interval (CI): 0.465-0.861; P = .038).

CONCLUSION

The present study suggests that osteoporosis treatment is associated with lower incidence of PPF following hip arthroplasty for femoral neck fractures. Treatment of osteoporosis should be initiated in eligible patients who sustain a femoral neck fracture, especially those who undergo hip arthroplasty.

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.

Detection of periprosthetic fractures around the femoral stem by resonance frequency analysis: An in vitro study

Periprosthetic femoral bone fractures are frequent complications of Total Hip Arthroplasty (THA) and may occur during the insertion of uncemented Femoral Stems (FS), due to the nature of the press-fit fixation. Such fracture may lead to the surgical failure of the THA and require a revision surgery, which may have dramatic consequences. Therefore, an early detection of intra-operative fractures is important to avoid worsening the fracture and/or to enable a peroperative treatment. The aim of this in vitro study is to determine the sensitivity of a method based on resonance frequency analysis of the bone-stem-ancillary system for periprosthetic fractures detection. A periprosthetic fracture was artificially created close to the lesser-trochanter of 10 femoral bone mimicking phantoms. The bone-stem-ancillary resonance frequencies in the range (2-12) kHz were measured on an ancillary instrumented with piezoelectric sensors, which was fixed to the femoral stem. The measurements were repeated for different fracture lengths from 4 to 55 mm. The results show a decrease of the resonance frequencies due to the fracture occurrence and propagation. The frequency shift reached up to 170 Hz. The minimum fracture length that can be detected varies from 3.1±1.7 mm to 5.9±1.9 mm according to the mode and to the specimen. A significantly higher sensitivity (p = 0.011) was obtained for a resonance frequency around 10.6 kHz, corresponding to a mode vibrating in a plane perpendicular to the fracture. This study opens new paths toward the development of non-invasive vibration-based methods for intra-operative periprosthetic fractures detection.

The AAHKS Clinical Research Award: Resurfacing the Thin Native Patella: Is It Safe?

BACKGROUND

Whether to resurface the patella during total knee arthroplasty (TKA) remains debated. One often cited reason for not resurfacing is inadequate patellar thickness. The aim of this study was to describe the implant survivorships, reoperations, complications and clinical outcomes in patients who underwent patellar resurfacing of a thin native patella.

METHODS

From 2000 to 2010, 7,477 patients underwent primary TKA with patellar resurfacing and had an intraoperatively, caliper-measured patella thickness at our institution. Of these, 200 (2.7%) had a preresection patellar thickness of ≤19 millimeters (mm). Mean preresection thickness was 18 mm (range, 12-19). Mean age was 69 years, mean body mass index was 31 kg/m², and 93% of the patients were women. Median follow-up was 10 years (range, 2-20).

RESULTS

At 10 years, survivorships free of any patella revision, patella-related reoperation, and periprosthetic patella fracture were 98%, 98%, and 99%, respectively. There were 3 patella revisions (1 aseptic loosening, 2 periprosthetic joint infections). There were 2 additional patella-related reoperations for patellar clunk. There were 3 nonoperatively managed periprosthetic patella fractures. Radiographically, all nonrevised knees had well-fixed patellae. Knee society scores improved from mean 36 points (interquartile range [IQR] 24-49) preoperatively to mean 81 points (IQR 77-81) at 10-year follow-up.

CONCLUSION

Resurfacing the thin native patella was associated with high survivorship free of patellar revision at 10-year follow-up. Nevertheless, there was 1 case of patellar loosening and 3 periprosthetic patella fractures. These risks must be weighed against the known higher incidence of revision when the thin native patella is left unresurfaced.

Ipsilateral Periprosthetic Fractures above and below the Knee Associated with Navigation Tracker Pin and Bone Fragility

We report a case of ipsilateral periprosthetic fractures above and below the knee that occurred at different times due to navigation tracker pin and bone fragility. A 66-year-old Japanese woman with rheumatoid arthritis (RA) underwent a total knee arthroplasty. Four months post-surgery, a periprosthetic fracture above the knee at the navigation pin hole was detected. She underwent osteosynthesis and could walk independently, but she developed an ipsilateral tibial component fracture. Conservative treatment with a splint was followed by bone union. Patients with RA treated with oral steroids tend to develop ipsilateral periprosthetic fractures around the knee due to bone fragility.

A Custom Device to Couple Proximal and Distal Femoral Stems: A Case Report and Literature Review

Complex periprosthetic fractures may occur with existing ipsilateral hip and knee implants. These cases are challenging with few options. We report on a custom coupler used to connect a hinged distal femoral replacement to an existing revision hip stem. This option was preferred to a total replacement of the femur. The custom coupler maintained the anatomic attachments of the proximal femur, preserved abductor strength during ambulation, and mitigated the morbidity which may arise from a total femur replacement. At 15 months postoperatively, the patient reported no pain, did not demonstrate an antalgic gait pattern, and had satisfactory range of motion at the hip and knee. The literature displays clinical and biomechanical efficacy for coupling devices although complications and device failure are quite variable.

Treatment of periprosthetic femoral fractures following total hip arthroplasty: results of an online survey of the European Hip Society

BACKGROUND

Periprosthetic femoral fractures (PPF) are a devastating complication after total hip arthroplasty (THA). Both trauma and adult reconstruction surgeons or combined teams treat these fractures following management algorithms. The aim of this study is to investigate the current treatment of PPF by members of the European Hip Society (EHS).

METHODS

An online survey of the members of the European Hip Society (EHS) was conducted. 20 cases of periprosthetic fracture were presented and surgeons were asked to answer questions regarding classification, treatment and postoperative treatment protocol.

RESULTS

A total of 132 (130 male; 2 female) EHS members responded. Mean years in surgical practice was 18.8 (min. 1 year; max. 50 years). The preferred surgical method was combined open reduction and internal fixation (ORIF) (30.3%) for AG fractures, ORIF with cables (30.4%) for AL fractures, combined ORIF (cable and plate) for B1 fractures (49.2%), stem revision with cables for B2 fractures (73.1%), stem revision with cables for B3 (55.9%) fractures and combined ORIF (cable and plate: 55.5%) for C fractures. Surprisingly, 10.8% suggested various stem revision techniques for B1 and 17.4% for C fractures. Strong variations were observed regarding postoperative weight-bearing protocol.

CONCLUSIONS

A strong consensus was found for the choice of conservative or surgical treatment of the different PPF types according to the Vancouver Classification. Various stem revision techniques were the preferred surgical techniques for Vancouver B2 (91.2%) and B3 (88.6%) fractures. However, for postoperative weight-bearing, when the ORIF technique was used, a significant variation of protocols was found.

Osteopetrosis is Associated With an Increased Risk for Intraoperative Periprosthetic Fracture in Total Hip Arthroplasty but not in Total Knee Arthroplasty

BACKGROUND

Osteopetrosis is a rare, inherited disorder in which bone remodels to become pathologically dense. There has been a paucity of data evaluating medical and surgical complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) in this patient population. The objective of this study was to evaluate osteopetrosis as a potential risk factor for medical and surgical complications following THA and TKA.

METHODS

Patients who had a diagnosis of osteopetrosis and underwent THA or TKA from 2010 to 2020 were identified in a national database. A total of 534 THA and 972 TKA patients who had osteopetrosis were identified and compared with matched cohorts of 2,670 and 4,860 patients, respectively. The rates of postoperative medical and surgical complications, hospital readmissions, and emergency room visits were calculated. In addition, reimbursements and lengths of stay were determined. Osteopetrosis patients were then compared to a 5:1 matched cohort without osteopetrosis using logistic regression analyses to control for additional confounding factors.

RESULTS

The osteopetrosis THA group had a substantially higher incidence of intraoperative periprosthetic fracture compared to the matched cohort (1.12% versus 0.19%, Odds Ratio 5.88, P = .005). Patients who had a history of osteopetrosis were not found to be at a significantly increased risk for other investigated medical or surgical complications compared to matched controls following THA or TKA.

CONCLUSION

Patients who had a history of osteopetrosis undergoing elective primary THA are associated with a significantly increased risk for intraoperative periprosthetic fracture. Patients with a history of osteopetrosis undergoing elective primary TKA were not found to be at an increased risk for any of the investigated complications.

The exeter cemented stem provides outstanding long-term fixation and bone load at 15 years follow-up: A systematic review and meta-analysis

PURPOSE

Since its introduction in 1988, the double-tapered polished Exeter cemented stem has been widely adopted in primary total hip arthroplasty (THA). Despite the results coming from the arthroplasty registries have proven great survivorship, the aim of this study was to dig deeper and describe the modes of failure of the Exeter stem at 15 years follow-up while reporting the clinical and radiographic outcomes.

METHODS

A search of PubMed, MEDLINE, and Embase was performed using the Preferred Reporting Items for Systematic Review and Meta-Analyses since inception of database to January 2022. A meta-analysis was performed on stem's failure rates and clinical outcomes using random effects models. Publication bias was assessed with funnel plots.

RESULTS

Overall, ten studies met the inclusion criteria with 2167 hips at mean 14.8 ± 4.1 years follow-up. The meta-effect estimate for revision rate for stem-related reasons was 3.8% (CI 95% 2.1-5.6, p < 0.01). The meta-effect for revision rate for stem aseptic loosening (AL) was 0.22% (CI 95% 0-0.4, p = 0.048) and for periprosthetic fracture was 0.6% (CI95% 0.3-0.9, p < 0.001). The meta effect estimate for Oxford Hip Score (OHS) at final follow-up was 32.4 (moderate; CI 95% 23.2-41.6, p <0.001) with and heterogeneity among the studies of I² 0%. Radiolucent lines were reported in 5.5% of cases, with 1.0% of cases (21 hips) reported to be progressive.

CONCLUSION

Current evidence suggests that the Exeter cemented stem not only has proven long-term outstanding reliability with a revision rate of 3.8%, but also incredibly low revision rates for AL (0.22%) and periprosthetic fracture (0.6%). It is suitable for a variety of indications, and the consistent radiological appearances indicate durable fixation and load transmission while being associated with a remarkably low stem-related complication rate.

Periprosthetic Fractures in Long Versus Short Proximal Femoral Nailing for Intertrochanteric Fractures: A 10-Year Single-Centre Cohort Study

Background Neck of femur (NOF) fractures, including intertrochanteric fractures, are common fragility fractures seen in the elderly population and are often amenable to fixation with a proximal femoral nail (PFN). However, there is conflicting evidence regarding the incidence of peri-prosthetic fractures with each device. Several studies from the 1990s and a recent meta-analysis have shown a higher incidence of peri-prosthetic fractures in the short PFN cohort. Other studies have shown a lower reoperation rate with short PFNs, and no statistically significant differences have been quoted in the rates of peri-prosthetic fractures in systematic reviews. Aim The purpose of this retrospective study, therefore, was to assess the peri-prosthetic fracture rate and failure rates of elderly neck of femur (NOF) fractures implanted with either a short or long proximal femoral nail (PFN). Materials and methods A retrospective study was conducted in a single orthopaedic department (University Hospital Dorset, Poole, GBR) using collected data on all extracapsular neck of femur fracture patients from the national hip fracture database (NHFD) from January 1, 2011, to December 23, 2021. The data collected included patient age, sex, the American Society of Anesthesiologists (ASA) type of neck of femur fracture, type of surgery performed, any further peri-prosthetic fractures, and time to re-operation in that subset of the group. The implants used were the Stryker Gamma 3 Nail and the Smith Nephew (Trigen and Intertan). All patients were allowed to fully weight bear as tolerated and received both orthopaedic and elderly medical care. Failure was defined as a cut-out or implant fracture. Results From January 1, 2011, to December 23, 2021, there were 1010 extracapsular neck of femur fractures recorded on the National Hip Fracture Database (NHFD) treated with a PFN from the study centre. Of those patients, 11 had pathological fractures and were excluded. 649 patients had long PFNs, and 350 had short PFNs. Of the total of 999 patients, 254 (25%) were male and 745 (75%) were female. More than 80% of the patients in the sample were over the age of 75. The majority of patients in both groups had A1/A2 fractures (short 84.3%, long 49.1%). The rate of periprosthetic fractures in the short PFNs was 1.71%, and the failure rate was 0.57%. The rate of periprosthetic fractures in the long PFNs was 0.62%, with a failure rate of 0.92%. The multi-nominal logistic regression model did not show statistically significant odds ratios (OR) for the following variables: long/short nails, male/female gender, age, ASA, or type of fracture. The female gender was associated with a higher risk of both periprosthetic fractures and failures (OR of 2.232 and 2.95), but this was not found to be statistically significant. Similarly, unstable A3 fractures had a much higher risk of failure (OR of 2.691) compared to periprosthetic fractures (OR of 0.985). However, this was not statistically significant. Conclusion Overall, this study has identified that in a patient population that is predominantly female and over the age of 75, the risk of periprosthetic fracture rate and the failure rate is similar in both the use of a short or a long PFN for intertrochanteric fractures.

Primary total hip arthroplasty failure: aseptic loosening remains the most common cause of revision

OBJECTIVE

Revision total hip arthroplasty (THA) imposes physical and financial burdens on patients and depletes limited medical resources. Causes for revision THAs can change as technology changes. Therefore, understanding contemporary causes is essential for clinical decision-making. We analyzed causes and trends associated with revision THA in the 2010s.

METHODS

We retrospectively identified 803 revision cases after primary THAs were performed at our center from January 2011 to December 2020. Causes for revision were reviewed and compared among patients who were grouped by the date of revision and interval between primary and revision THA.

RESULTS

The most common causes were aseptic loosening (66.6%), infection (11.0%), osteolysis (6.0%), periprosthetic fracture (5.5%), and instability (3.5%). The values for incidence of infection, fracture, and instability were higher in the early revision group than in the late revision group (threshold, 2 years after primary surgery, all P<0.05). The proportion of revision THAs increased by 25.6% from 2011-2015 to 2016-2020, and the time between primary and revision THAs increased from 8.8 ± 7.0 years to 10.2 ± 6.8 years (P=0.003). In the last 5 years of the study period, the incidence of aseptic loosening decreased and the rates of osteolysis, acetabular wear by hemiarthroplasty, and instability increased, compared to 2011-2015 (all P<0.05).

CONCLUSIONS

Aseptic loosening was the most common cause of revision THA. Revisions due to infection, fracture, and instability occurred more frequently during the early post-THA period after primary THA. Revisions due to osteolysis, instability, and acetabular wear have increased in recent years.

Total hip arthroplasty revision etiologies: a cross-sectional study in Isfahan, Iran

BACKGROUND

Complications after primary total hip arthroplasty (THA) are the most common reason for revision. Due to the high prevalence of revision surgery, we investigated the frequency of postprimary THA complications and related risk factor revision surgery.

MATERIALS AND METHODS

This is a cohort study that was performed in 2011-2019 on all patients who underwent primary THA surgery re-admitted to the Kashani and Saadi Hospital affiliated to Isfahan University of Medical Science, Iran, due to some complications after THA. Demographic and basic data were collected from patient's medical documents. Harris hip score (HHS) was calculated for all patients 6 months after the last surgery. The obtained data were analyzed using SPSS software version 21. Appropriate statistical tests were conducted to compare the results between the study groups.

RESULTS

Among 1260 patients who underwent primary THA, 1006 of them entered the study after applying the exclusion criteria. Thirty nine patients were under revision, 53.8% had prosthesis infection, 56.4% had instability, 6% had aseptic loosening, and 30.8% had periprosthetic fracture. Odds ratio for the above complications were 45.5, 45, 6.4, and 15.5, respectively. HHS postoperatively was also significantly (P < 0.001) higher in patients without revision. No correlation between gender or surgeon experience and revision was detected; however wound discharge (P < 0.001), body mass index (BMI) (P = 0.003), and Infection during hospitalization (P < 0.001) affect revision rate significantly. All four postsurgery complications, i.e., instability, postoperative prothesis infections, periprosthetic fractures, and aseptic loosening, significantly increased the risk of revision (P < 0.001, for all).

CONCLUSION

Instability, prosthetic infections, periprosthetic fractures, and aseptic loosening were the most common causes for increasing revision rates after THA, respectively. Higher BMI, persistent wound discharge, and nosocomial infections during the first hospitalization also increased the rate of revision after primary THA.

Cemented Femoral Fixation in a High-Risk Cohort Diminishes Risk of Early Postoperative Periprosthetic Fracture

BACKGROUND

Early periprosthetic fractures (PPFx) following primary total hip arthroplasty (THA) create significant morbidity. Established risk factors for early PPFx include age, gender, body mass index, surgical approach, and implant fixation. We investigated the role of femoral fixation on early PPFx (<90 days postoperatively) in a high-risk cohort undergoing direct anterior approach (DAA) THA.

METHODS

The final cohort comprised 344 consecutive patients (390 hips) with risk factors for PPFx (age >68 years and body mass index <25 kg/m2) who underwent primary DAA THA between May 4, 2009 and December 31, 2019 and had 90-day follow-up. Noncemented fixation was used in 229-hips, while cemented fixation was used in 161 hips. The primary outcome was early PPFx. Fisher's exact test was used for categorical variables, while t-tests were used to compare continuous variables.

RESULTS

We observed 8 early PPFx (2.1%), all fractures occurring in the noncemented group. Baseline demographics were similar but not equal, with the cemented group being older (78.0 versus 76.3 years; P = .004) with a greater proportion of females (91.9% versus 69.4%; P < .001). The rate of early PPFx was significantly higher with noncemented fixation compared to cemented fixation (3.5% versus 0.0%; P = .023). A post hoc power analysis confirmed sufficient power (1-β = 0.81).

CONCLUSION

Although baseline risk factors for early PPFx are not easily modifiable, surgical factors can be modified. Cemented fixation has the potential to markedly reduce the risk of early PPFx in high-risk patients undergoing DAA THA.

Clinical and Radiological Outcome of Vancouver B2 Fracture Treated With Open Reduction and Internal Fixation. A Multicenter Cohort Analysis

OBJECTIVES

To determine whether open reduction and internal fixation (ORIF) of periprosthetic Vancouver B2 fractures can lead to successful fracture healing in selected patients, when attention is given to the surgical exposure and the creation of a balanced extramedullary construct.

DESIGN

Retrospective.

SETTING

Two Level-1 trauma centers in Germany and United Kingdom.

METHODS

Patients with a B2 fracture receiving solely ORIF using a polyaxial locking plate were included for analysis. Patients with other fracture types, or treated with other methods, or with follow-up less than 12 months were excluded. Clinical characteristics, including the Charlson index, the American Society for Anesthesiologists score, and their preinjury functional levels, were recorded. Main outcome measures were 1-year mortality, revision rate, and radiological healing according to the Beals-Tower criteria.

RESULTS

A total of 32 patients (mean age ,79 ± 12 years) were enrolled. Six patients died within the first year (1-year mortality: 19%), and 5 were unavailable for follow-up studies. The remaining 21 patients had a mean follow-up of 30 months. Of 21, 20 had an excellent/good result using the criteria of Beals-Tower. One patient required revision surgery due to loosening and secondary subsidence of the stem.

CONCLUSION

ORIF can be offered to selected patients suffering from B2 fractures, especially if their functional demand is limited, and perioperative risk high for revision arthroplasty. In this challenging cohort of patients, ORIF was a safe and effective therapeutic option.

LEVEL OF EVIDENCE

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

Risk Factors for Periprosthetic Femoral Fracture in Non-cemented Total Hip Arthroplasty Through the Direct Anterior Approach

Background: Although total hip arthroplasty (THA) performed through the direct anterior (DA) approach is frequently marketed as superior to other approaches, there are concerns about increased risks of intraoperative and early postoperative femoral fracture. Purpose: We sought to assess patient-specific and radiographic risk factors for intraoperative and early postoperative (90-day) periprosthetic femoral fracture (PPFx) following DA approach THA. Methods: We retrospectively reviewed 1107 consecutive, primary, non-cemented DA THAs, performed between April 2009 and January 2015, for intraoperative and early postoperative PPFx. Patients lost to follow-up before 90 days (63), cemented or hybrid THA (52), or early femoral failure for another indication (3) were excluded, yielding 989 hips for analysis. Demographic variables and patient comorbidities were analyzed as risk factors for PPFx. Continuous variables were initially compared with 1-way analysis of variance (ANOVA) and categorical variables with chi-square test. A demographic matched-paired radiographic analysis was performed for femoral stem canal fill and compared using univariate logistic regression. Results: The incidence of perioperative PPFx was 2.02%, including 10 intraoperative and 10 early postoperative fractures. Sustaining a postoperative PPFx was associated with being 70 years old or older with a body mass index (BMI) of less than 25, or with having either osteoporosis or Parkinson disease. Radiographs demonstrated that intraoperative PPFx was associated with stems that filled greater proximally rather than distally. Conclusion: Our cohort study found older age, age over 70 with BMI of less than 25, osteoporosis, and Parkinson disease were associated with increased risk for early postoperative PPFx following DA approach THA. Intraoperative fractures may occur with disproportionate proximal femoral canal fill. Further study can evaluate whether cemented femoral components may mitigate risk in these patient populations.

Charcot-Marie-Tooth Disease as a Risk Factor for Periprosthetic Fractures in Tibiotalocalcaneal Fusion With Intramedullary Nailing

Introduction The treatment for severe fixed hindfoot osteoarthritis secondary to Charcot-Marie-Tooth disease (CMT) is tibiotalocalcaneal (TTC) arthrodesis. In our centre, we have noticed a disproportionate rate of periprosthetic fractures in CMT patients following TTC arthrodesis with retrograde hindfoot nailing. The aim of this study was to test this hypothesis by evaluating our local cohort of TTC arthrodesis with retrograde hindfoot nailing. Methods A retrospective review of patients who had TTC arthrodesis with intramedullary nailing was conducted over a seven-year period. Results There were 45 patients (30 male, 15 female) in our cohort. Forty-one patients achieved radiological and clinical fusion of their TTC arthrodesis. All three patients who had CMT sustained periprosthetic fracture at the tip of the nail at an average of four (range: 2.5-6) months from index operation. In comparison, no patients in the rest of the cohort sustained periprosthetic fractures. The nail position of the patients with CMT was central in both planes in all three patients. None of the patients with CMT had abutment of the cortex on either plane. Conclusion We found that there was a disproportionate rate of periprosthetic fractures in CMT patients in our cohort of TTC arthrodesis with retrograde hindfoot nailing. This suggests that CMT is a significant risk factor. The authors propose a longer nail to reduce the lever arm, with a long period of protected weight bearing till union, followed by consideration of elective removal of the nail to prevent this phenomenon from occurring.

Causes of Early Hip Revision Vary by Age and Gender: Analysis of Data From a Statewide Quality Registry

BACKGROUND

While total hip arthroplasty (THA) is extremely successful, early failures do occur. The purpose of this study was to determine the cause of revision in specific patient demographic groups at 3 time points to potentially help decrease the revision risk.

METHODS

Data for cases performed between 2012 and 2018 from a statewide, quality improvement arthroplasty registry were used. The database included 79,205 THA cases and 1,433 revisions with identified etiology (1,584 in total). All revisions performed at <5 years from the primary THA were reviewed. Six groups, men/women, <65, 65-75, and >75 years, were compared at revision time points <6 months, <1 year, and <5 years.

RESULTS

There were obvious and significant differences between subgroups based on demographics and time points (P < .0001). Seven hundred and fifty-six (53%) of all revisions occurred within 6 months. The most common etiologies within 6 months (756 revisions) were fracture (316, 41.8%), dislocation/instability (194, 25.7%), and infection (98, 12.9%). At this early time point, the most common revision cause was fracture for all age/gender-stratified groups, ranging from 27.6% in young men to 60% in older women. Joint instability became the leading cause for revision after 1 year in all groups.

CONCLUSION

This quality improvement project demonstrated clinically meaningful differences in the reason for THA revision between gender, age, and time from surgery. Strategies based on these data should be employed by surgeons to minimize the factors that lead to revision.