Abstract
This study will seek to identify a measurable radiographic index, the Metaphyseal-Diaphyseal Index (MDI) score to determine whether intra-operative fracture in osteoporotic bone can be predicted.A 5 year prospective cohort of 560 consecutive patients, undergoing hemiarthroplasty (cemented or uncemented), was evaluated. A nested case-control study to determine risk factors affecting intra-operative fracture was carried out.The Vancouver Classification was used to classify periprosthetic fracture.The MDI score was calculated using radiographs from the uncemented group. As a control (gold standard), Yeung et al's Canal Bone Ratio (CBR) score was also calculated. From this, a receiver operating characteristic (ROC) curve was formulated for both scores and area under the curve (AUC) compared. Intra and inter-observer correlations were determined.Cost analysis was also worked out for adverse outcomes.Four hundred and seven uncemented and one hundred and fifty-three cemented stems were implanted. The use of uncemented implants was the main risk factor for intra-operative periprosthetic fracture.Sixty-two periprosthetic fractures occurred in the uncemented group (15.2%), nine occurred in the cemented group (5.9%), P < 0.001. The revision rate for sustaining a periprosthetic fracture (uncemented group) was 17.7%, P < 0.001 and 90 day mortality 19.7%, P < 0.03.MDI's AUC was 0.985 compared to CBR's 0.948, P < 0.001. The MDI score cut-off to predict fracture was 21, sensitivity 98.3%, specificity 99.8%, positive predictive value 90.5% and negative predictive value 98%. Multivariate regression analysis ruled out any other confounding factors as being significant.The intra and inter-observer Pearson correlation scores were r = 0.99, P < 0.001.JRI uncemented hemiarthroplasty has a significantly higher intra-operative fracture rate. We recommend cemented arthroplasty for hip fractures. We propose a radiographic system that may allow surgeons to select patients who are good candidates for uncemented arthroplasty, but it needs prospective validation.
Highlights
The issue of using a cemented or uncemented femoral stem for hip hemi-arthroplasty has still not been resolved [1]
71 (12.7%) patients sustained intra-operative fracture and 489 (87.3%) did not, P < 0.001.Comparing the cases and controls, the only risk factor that significantly affected fracture incidence was whether a cemented (12.7% fracture rate) or uncemented prosthesis was used (87.3% fracture rate, odds ratio 3.4, 95%CI 1.61-8.10, P < 0.001). This confirms that uncemented JRI hydroxyapatite coatings (HAC) LOL stems are the main risk factor for sustaining an intraoperative fracture
This study confirms that the use of modern uncemented JRI HAC LOL stem for hemiarthroplasty carries a significantly higher risk of sustaining intra-operative periprosthetic fracture (15.2%, odds ratio 3.4, P < 0.001)
Summary
The issue of using a cemented or uncemented femoral stem for hip hemi-arthroplasty has still not been resolved [1]. Most rigorously conducted studies cannot show any significant difference in major medical complications between cemented and uncemented hemi-arthroplasty [1]. The concerns with uncemented stems, the most common of which is the Austin Moore prosthesis, are loosening, thigh pain and peri-prosthetic fracture, which occur intra or post-operatively requiring further surgery in an already debilitated population. This is associated with an increase in morbidity and mortality [1,2,3,4,5]. Current evidence suggests that this classical prosthesis be reserved for only those patients with a low ambulatory potential [5,7]
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