Femoral Complications Research Articles

Low Rate of Early Periprosthetic Fractures in Direct Anterior Total Hip Arthroplasty with a Triple-Tapered Wedge Stem.

Utilization of the direct anterior approach (DAA) for total hip arthroplasty (THA) has been steadily increasing in recent years. While the DAA may offer some benefits compared to other approaches, there are still risks involved including relatively higher rates of periprosthetic femur fractures, especially when combined with cementless femoral stem use. The purpose of this study is to evaluate the early postoperative femoral complications with a short triple-wedge tapered stem used in primary THA via a DAA. A retrospective review was conducted of the arthroplasty registry of our institution from April 2022 to August 2023 to identify patients who underwent a primary THA via a DAA with the Short Medacta Stem (SMS) (Medacta International, Castel San Pietro, Switzerland). Patients were excluded if the stem was used for a revision surgery, they were within 90 days of surgery, or they refused research consent. Inclusion criteria was met in 262 patients (302 hips). Data was collected after reviewing the chart, and reports and radiographic measurements, including Dorr type and canal fit ratios, were obtained from preoperative and postoperative radiographs, respectively. A total of 302 total hips were included, 161 patients were male (53.3%) and 141 were female (46.7%), with an average age of 66.5 years (27-88, +/- 10.7 years). Average follow up was 0.3 years (range, 0.05-1.71 years). The majority of patients had a Dorr B femur (81.7%). The Median stem size used was an 8 (range, 2-15), and 89.4% of those had a collar. Average canal fill ratio was 0.83 (range, 0.43-0.98, +/- 0.07). Overall, there were two Vancouver B2a periprosthetic femoral shaft fractures (0.66%) that required revision surgery to a modular stem. In addition, there were two Vancouver Ag greater trochanteric fractures (0.66%) with acceptable alignment that did not require revision surgery. Demographic information about the patients with femoral complications is summarized in Table I. Average age of patients with femoral complications was 69.5 years, with an average canal fit ratio of 0.88. We found that the triple-wedge implant had a low rate of early femoral complication in primary THA from an anterior approach and is safe for use in THA from a DAA. More follow up is needed to evaluate continuing implant survivorship and patient outcomes.

A comparison of cemented femoral fixation via anterior versus posterior approach total hip arthroplasty: an analysis of 60,739 total hip arthroplasties.

Anterior approach total hip arthroplasty (THA) decreases the rate of dislocation but increases femoral-sided complications in the way of periprosthetic fractures and component loosening. A cemented prosthesis may reduce femoral-sided complications and improve the risk:benefit profile of anterior approach THA. Data from the Australian National Joint Replacement Registry were analysed for patients undergoing primary THA via the anterior or posterior approach using a cemented polished femoral stem from January 2015 to December 2021. The primary outcome measure was the cumulative percent revision (CPR) for all causes and CPR for femoral component loosening and fracture. The CPR for the primary outcome measures were compared between the anterior and posterior approach and adjusted for age, sex, ASA score, BMI and femoral head size. The study included 60,739 THAs with cemented stems (10,742 anterior, 49,997 posterior). The rate of revision of the anterior versus the posterior approach did not significantly differ (HR 0.87 (95% CI, 0.74-1.03), p = 0.100). Anterior approach THA had a significantly higher rate of revision for femoral component loosening (HR 5.06 [95% CI, 3.08-8.30], p < 0.001); and a decreased rate of revision for infection (HR 0.59 [95% CI, 0.43-0.81], p = 0.001) and dislocation/instability (HR 0-3 months 0.48 [95% CI, 0.27-0.83], p = 0.008; HR >3 months 0.30 [95% CI, 0.15-0.61], p < 0.001). There was no difference in the rate of revision surgery for fracture between the 2 approaches (HR 1.01 [95% CI, 0.71-1.43]), p = 0.975). There is no significant difference in overall revision rates with cemented femoral fixation performed with an anterior or posterior approach. Cemented fixation performed with the anterior approach partly mitigates femoral complications with no difference in the revision rate for fracture but an increased rate of femoral component loosening.

A single center study of the efficacy and safety of Pro-Glide used for closure in thoracic endovascular aortic repair in patients with previous groin intervention.

This study aimed to evaluate the efficacy and safety of Pro-Glide, a suture-mediated vascular closure device, regarding technical success and complications in patients who had undergone aortic intervention and had previous groin intervention (PGI). One hundred and thirty-five patients who underwent percutaneous thoracic endovascular aortic repair via the femoral artery and were closed with the Pro-Glide device were analyzed retrospectively. PGI was defined as a history of open surgical access to the femoral artery or wide sheath (>18 F) placement due to endovascular or valvular intervention. The patients were divided into two groups 38 cases with PGI and 97 cases without PGI. The overall success rate of closure of the femoral artery with Pro-Glide was not statistically significant between the two groups (93.8% vs 92.1%, p = .711). Sheath sizes were compared between the groups and PGI (+) group had significantly higher sheath sizes compared to PGI (-) group (24.3 ± 1.1 F vs 23.8 ± 1.0 F, p = .011). Three patients in the PGI (+) group and six patients in the PGI (-) group experienced technical failure of the percutaneous femoral approach. Femoral complications were seen after the procedures in four patients in the PGI (+) group and four in the PGI (-) group. The PGI (+) group had a higher complication rate when compared to the PGI (-) group; however, this was not statistically significant (p = .181). The present study was conducted on a significantly larger sample compared to previous studies and the findings suggest that the Pro-Glide vascular closure device is a safe option for patients with a history of PGI and may not be considered as a contraindication.

Subtrochanteric femoral fractures and intramedullary nailing complications: a comparison of two implants

IntroductionIntramedullary (IM) nails are considered the ‘gold’ standard treatment for subtrochanteric femoral fractures. The incidence and risk factors for re-operation in subtrochanteric fractures remain unclear. Furthermore, no studies have compared the outcomes of different nailing systems used to treat subtrochanteric fractures in the same study population.Aims/objectivesOur study aimed to (i) investigate the cumulative incidence and factors associated with an increased risk of re-operation in subtrochanteric fractures treated with a long intramedullary (IM) nail, (ii) compare the outcomes of subtrochanteric fractures treated with long Affixus and Gamma nails, and (iii) establish whether the addition of a proximal anti-rotation screw in the Affixus nail confers any clinical benefit.MethodsA retrospective review of all adult patients admitted to a level 1 trauma centre with a subtrochanteric femur fracture treated with a long cephalomedullary IM nail over an 8-year period was conducted. Exclusion criteria were primary surgery performed at another institution, prophylactic nailing because of tumours, incomplete fractures, and patients who were lost to follow-up or died before fracture healing. Data variables were assessed for normality prior to determining the use of either parametric or non-parametric tests. Logistic regression analysis was performed to identify potential factors associated with re-operation. For the comparison between the two nail types, patients were matched into two groups of 119 each by age (10-year intervals), gender and mechanism of injury (low energy, high energy and pathological fractures). A p-value < 0.05 was considered significant. The Kaplan–Meier nail survival curve was used to demonstrate the survival of each nail. Data were analysed using the statistical package R (R version 3.6.0).ResultsA total of 309 subtrochanteric fractures were treated with a distally locked long IM nail (re-operation rate: 22.33%) over an 8-year period. Logistic regression identified six factors associated with an increased risk of re-operation, including age < 75 years old, use of a long Gamma nail, pre-injury coxa-vara femoral neck shaft angles, an immediate post-operative reduction angle of > 10° varus, deep wound infection and non-union.Following matching, we compared the two long cephalomedullary nailing systems used (Gamma versus Affixus nail). The only differences identified from the unadjusted analysis were a higher overall incidence of nail failure in Gamma nails due to any cause, re-operation, and impingement of the nail tip distally against the anterior femoral cortex. When we corrected for covariates, no significant differences remained evident between the two nails. From the Kaplan–Meier nail survival curves, however, the Affixus nail demonstrated better survivorship up to 5 years post-implantation in terms of nail failure and re-operation for all causes. Finally, the addition of a proximal anti-rotation screw in the Affixus nail did not seem to confer any benefit.ConclusionWe reported a 22.3% re-operation rate in our cohort of subtrochanteric fractures treated with a long IM nail. We have identified six risk factors associated with re-operation: age < 75 years old, pre-injury femoral neck shaft angle, choice of nail, varus reduction angle, fracture-related infection and non-union. The addition of a proximal anti-rotation screw in the Affixus nail did not confer any benefit.

Avoiding the Radial Paradox: Neuroendovascular Femoral Access Outcomes After Radial Access Adoption.

Transradial access (TRA) for neuroendovascular procedures is increasing in prevalence. The safety benefits of TRA at a patient level may be offset at a population level by a paradoxical increase in transfemoral access (TFA) vascular access site complications (VASCs), the so-called "radial paradox." To study the effect of TRA adoption on TFA performance and outcomes in neuroendovascular procedures. Data were collected for all procedures performed over a 10-mo period after radial adoption at a single center. Over the study period, 1084 procedures were performed, including 719 (66.3%) with an intent to treat by TRA and 365 (33.7%) with an intent to treat by TFA. Thirty-two cases (4.4%) crossed over from TRA to TFA, and 2 cases (0.5%) crossed over from TFA to TRA. TFA was performed in older patients (mean [standard deviation] TFA, 63 [15] vs TRA, 56 [16] years) using larger sheath sizes (≥7 French; TFA, 56.2% vs TRA, 2.3%) ( P < .001 for both comparisons). Overall, 29 VASCs occurred (2.7%), including 27 minor (TFA, 4.6% [18/395] vs TRA, 1.3% [9/689], P = .002) and 2 major (TFA, 0.3% [1/395] vs TRA, 0.1% [1/689], P > .99) complications. Independent predictors of VASC included TFA (OR 2.8, 95% confidence interval [CI] 1.1-7.4) and use of dual antiplatelet therapy (OR 4.2, 95% CI 1.6-11.1). TFA remains an important access route, despite a predominantly radial paradigm, and is disproportionately used in patients at increased risk for VASCs. TFA proficiency may still be achieved in predominantly radial practices without an increase in femoral complications.

Cemented femoral stem fixation through the anterior approach has fewer early complications than cementless fixation.

To achieve the functional benefits of the direct anterior (DA) approach and the fixation benefits of cemented replacement, this study combined the two techniques posing the following questions: does the limited access of the DA approach adversely affect the cement technique?; and does such a cementing technique reduce the incidence of cementless complications? A consecutive series of 341 patients (360 hips) receiving the DA approach between 2016 and 2018 were reviewed. There were 203 cementless stems and 157 cemented stems. Mean age was 75 years (70 to 86) in the cementless group and 76 years (52 to 94) in the cemented group, with 239 (70%) females in the whole series. Femoral complications were compared between the two groups. Mean follow-up was 1.5 years (0.1 to 4.4) for patients in the cementless group and 1.3 years (0.0 to 3.9) for patients in the cemented group. The cementless group had a higher rate of femoral complications (8 vs 0; p = 0.011). There were two loose stems and six fractures, all requiring revision. Fractures occurred a mean 14.5 days (2 to 31) postoperatively and loosening at 189 days and 422 days postoperatively. Femoral cementing can be done using the DA approach safely and reduces the number of complications compared with a contemporary cementless series. A higher rate of early fractures and loosening occurred with cementless stems. This was not observed in our cemented stem cohort and cementing was safely accomplished through the DA approach. The modern femoral cementing process with the DA approach does not add to surgical complexity or time, has fewer early complications, and is a safer option for older patients compared to cementless femoral arthroplasties. Cite this article: Bone Joint J2021;103-B(7 Supple B):33-37.

ProGlide venous closure device facilitates early ambulation following cryoablation of atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Heart Foundation Background Same-day discharge following atrial fibrillation (AF) ablation is increasingly common. ProGlide device suture-mediated vascular closure (PD) offers a technique that may expedite mobilisation following large-bore (&amp;gt;12F) venous access. The utility of PD closure following cryoablation of AF has not been reported. Purpose We sought to evaluate haemostasis and early ambulation outcomes in patients receiving the ProGlide compared with conventional techniques. Methods 104 consecutive patients undergoing cryoballoon pulmonary vein isolation (PVI) for paroxysmal or persistent at a single high-volume institution were included. PVI was performed via a standardised approach including sedation, ultrasound-guided vascular access for 14F Cryosheath and second 7F sheath, anticoagulation protocol, transeptal puncture, 28mm cryoballoon and nurse-led same-day discharge protocol. Haemostasis was achieved using the Perclose Proglide device (PD) in the 14F access point ("pre-closure" technique) plus 5 minutes manual pressure at the 7F sheath site. Alternatively, a figure-of-eight/Z-suture (ZS) was employed for closure according to operator preference. Protamine was used for heparin reversal in all patients. Safety outcomes of major bleeding, haematoma and minor bleeding were assessed. Time to ambulation (TTA), time to discharge (TTD), same-day discharge and complications at initial follow-up were measured. Results Overall, mean age was 64 ± 11 years, 65 (64%) were male and 52 (50%) of patients had paroxysmal AF, there were no significant differences between group demographics, with 31 patients (30%) in the PD group and 73 (70%) in the ZS group. All patients had uninterrupted oral anticoagulation throughout the periprocedural period. No major femoral bleeding complications requiring intervention occurred in either group. Haematomas occurred in none of the PD group compared with 2 (2.8%) in the ZS group. Incidence of minor bleeding was not significantly different between groups (PD: 3 [9.7%] vs ZS: 2 [2.7%], p = 0.155). Mean TTA was significantly shorter in the PD group (3.3 ± 1.1 vs 4.1 ± 1.7 hrs, p = 0.025). However, there was no significant difference in same-day discharge (PD: 25 [81%] vs ZS: 53 [73%], p = 0.386) and TTD (5.0 ± 3.6 vs 6.1 ± 4.2 hrs, p = 0.275) between groups. 1 patient complained of groin pain which delayed discharge in the ZS group not seen in the PD group. After a mean follow-up of 2.2 ± 1.4 months, there were no differences in major or minor complications. Conclusion Use of the Proglide closure device was associated with significant reductions in time to ambulation compared with Z-suture haemostasis following cryoablation of AF, and groin access complications were uncommon across groups. PD closure may contribute to further streamlining patient pathways in day-case AF ablation.

Intraoperative Complications and Early Return to the Operating Room in Total Hip Arthroplasty Performed Through the Direct Anterior and Posterior Approaches. An Institutional Experience of Surgeons After Their Learning Curve

BackgroundProponents of the direct anterior approach (DAA) for total hip arthroplasty (THA) claim a faster recovery, whereas critics claim an increased risk of early femoral complications. This study analyzed intraoperative and postoperative complications requiring reoperation within one year after THA through the DAA and posterior approach (PA). MethodsA total of 2348 elective, unilateral DAA THAs in patients with osteoarthritis performed between 2016 and 2019 were matched 1:1 for age (±5 years), gender, body mass index (±5), and femoral fixation with 2348 patients who underwent PA THA during the same period. Mixed-effects logistic regression was used. Odds ratios were reported for the occurrence of intraoperative femoral fracture, postoperative femoral fracture, infection, dislocation, and other etiologies requiring reoperation within one year. ResultsIntraoperative femoral fracture occurred in 12 DAA (0.5%) and 14 PA (0.6%) patients. Twenty-five patients (1.06%) in the DAA and 28 (1.19%) in the PA group underwent reoperation within the first year. Reoperations were due to periprosthetic fracture (40%), infection (28%), dislocation (23%), and other (9%). Regression analysis revealed no difference in intraoperative femoral fracture (odds ratio (OR): 0.86, 95% confidence interval (CI): 0.40-1.86, P = .69), postoperative femoral fracture (OR: 1.10, 95% CI: 0.47-2.60, P = .83), infection (OR: 1.50, 95% CI: 0.53-5.23, P = .44), or reoperation within one year for other reasons (OR: 1.50, 95% CI: 0.25-9.00, P = .65). DAA had fewer dislocations requiring reoperation (OR: 0.20, 95% CI: 0.04-0.91, P = .02). ConclusionThis comparative study did not find differences in intraoperative or postoperative fracture or infection between DAA and PA. DAA was associated with a lower likelihood of reoperation for dislocation within one year of surgery.

Abstract P541: Avoiding the Radial Paradox: Radial Adoption is Not Associated With Worse Femoral Outcomes in Neuroendovascular Cases

Background and Purpose: Transradial access (TRA) for neuroendovascular procedures is increasing in prevalence, although numerous procedures are still performed using transfemoral access (TFA). Some cardiology studies have suggested the safety benefits of TRA at a patient level may be offset at a population level by a paradoxical increase in TFA vascular access site complications (VASCs) associated with radial adoption, the so-called “radial paradox.” We studied the effect of TRA adoption on TFA performance and VASC rates in neuroendovascular procedures. Methods: Data were collected for all neuroendovascular procedures performed over a 10-month period by trainees after implementation of a radial-first paradigm at a single center. Results: Over the study period, 1,084 procedures were performed, including 689 (63.6%) via TRA and 395 (36.4%) via TFA. In comparison to TRA, TFA cases were performed in older patients (TFA 63 ±15 vs. TRA 56 ±16), were predominantly male (TFA 52.9% vs. TRA 38.6%), used larger sheath sizes (≥7 French, TFA 56.6% vs. TRA 2.3%), were more often emergent (TFA 37.7% vs. TRA 1.1%), and used tPA administration (TFA 15.3% vs. TRA 0%) (p&lt;.001 for all comparisons). Overall, 29 VASCs occurred (2.7%), including 27 minor (TFA 4.6% [18/395] vs. TRA 1.3% [9/689], p=.002) and 2 major (TFA 0.3% [1/395] vs. TRA 0.1% [1/689], p&gt;.99) complications. After multivariate analysis, independent predictors of any VASC included TFA (OR 2.8, 95% CI 1.1-7.4) and use of dual antiplatelets (OR 4.2, 95% CI 1.6—11.1). Conclusions: TFA remains an essential route for neuroendovascular procedures, accounting for 36.4% of cases under a radial-first paradigm. TFA is disproportionately performed in patients undergoing procedures with an increased-risk for VASCs, though the minor and major VASC rates are comparable to historical controls. TFA proficiency may still be achieved in radial-first training without an increase in femoral complications.

Diagnosis and Management of Intraoperative Fractures in Primary Total Hip Arthroplasty.

Intraoperative periprosthetic fractures are challenging complications that may affect implant stability and survivorship. Periprosthetic acetabular fractures are uncommon and infrequently are the focus of studies. Acetabular fractures are occasionally recognized after patients report unremitting groin pain weeks postoperatively. The widespread use of cementless acetabular cups might lead to higher number of fractures than is clinically detectable. Conversely, the incidence of intraoperative periprosthetic femoral fractures are more common and encompass a broad spectrum, ranging from a small cortical perforation to displaced fractures with an unstable prosthesis. Appropriate recognition, including mindfulness of preoperative patient and surgical risk factors, is critical to the successful management of acetabular and femoral complications. This comprehensive review article focuses on the incidence, patient and surgical risk factors, diagnosis, management, and clinical outcomes associated with intraoperative acetabular and femur fractures in primary total hip arthroplasty.

The effect of femoral stem collar on implant migration and clinical outcomes following direct anterior approach total hip arthroplasty.

The direct anterior (DA) approach has been associated with rapid patient recovery after total hip arthroplasty (THA) but may be associated with more frequent femoral complications including implant loosening. The objective of this study was to determine whether the addition of a collar to the femoral stem affects implant migration, patient activity, and patient function following primary THA using the DA approach. Patients were randomized to either a collared (n = 23) or collarless (n = 26) cementless femoral stem implanted using the DA approach. Canal fill ratio (CFR) was measured on the first postoperative radiographs. Patients underwent a supine radiostereometric analysis (RSA) exam postoperatively on the day of surgery and at two, four, six, 12, 26, and 52 weeks postoperatively. Patient-reported outcome measures (Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index, the 12-item Short Form Health Survey Mental and Physical Score, and University of California, Los Angeles (UCLA) Activity Score) were measured preoperatively and at each post-surgery clinic visit. Activity and function were also measured as the weekly average step count recorded by an activity tracker, and an instrumented timed up-and-go (TUG) test in clinic, respectively. Comparing the RSA between the day of surgery baseline exam to two weeks postoperatively, subsidence was significantly lower (mean difference 2.23 mm (SD 0.71), p = 0.023) with collared stems, though these patients had a greater CFR (p = 0.048). There was no difference (p = 0.426) in subsidence between stems from a two-week baseline through to one year postoperatively. There were no clinically relevant differences in PROMs; and there was no difference in the change in activity (p = 0.078) or the change in functional capacity (p = 0.664) between the collared stem group and the collarless stem group at any timepoint. Presence of a collar on the femoral stem resulted in reduced subsidence during the first two postoperative weeks following primary THA using the DA approach. However, the clinical implications are unclear, and larger studies examining patient activity and outcomes are required. Cite this article: Bone Joint J 2020;102-B(12):1654-1661.

Clinical efficacy and safety of the PRO-glide device as a sUture-mediated ClosurE in Thoracic EndoVascular Aortic Repair in patients with previous groin intervention (from the PRODUCE-TEVAR Trial).

While the percutaneous approach is increasingly preferred, suture-mediated closure devices have been put into clinical practice to close the femoral artery during procedures requiring a large-sized introducer. However, scar in the groin is considered a contraindication or an exclusion criterion for percutaneous procedures. The aim of our study was to investigate the outcomes and safety of Pro-Glide device as suture-mediated closure device in patients who underwent thoracic endovascular aortic repair with percutaneous femoral access ≥22 F who had previous groin intervention. A total of 73 patients who underwent endovascular repair with percutaneous femoral access were retrospectively included in the study. Previous groin intervention was defined as history of open surgical access or large sheath insertion (>18 F) to femoral artery because of endovascular or valvular intervention. Patients were divided into two groups as who had previous groin intervention PGI (+) and had not PGI (-). A total of 73 patients [60 male (82.2%)] were included in the study. Seventeen patients had PGI, and 56 did not. When groups were compared in terms of sheath sizes, a significantly higher sheath sizes were used in PGI (+) patients (24.5 ± 1.1 F vs. 23.8 ± 0.9 F, p = 0.005). The overall success rate in the femoral approach with pre-close technique was statistically insignificant between two groups (94.1% vs. 96.4%, p = 0.55). One patient in PGI (+) group and two patients in PGI (-) had technical failure for percutaneous femoral approach. One patient (5.9%) in PGI (+) group and one patient (1.8%) in PGI (-) group had femoral complications after the procedures; however, there was no significant difference between the groups in terms of complications (5.9% vs. 1.8%, p = 0.13). Pro-Glide device may be a safe and less invasive method for femoral access in patients with PGI and might not be considered as a contraindication for patients with history of PGI.

Early Rate of Revision of Total Hip Arthroplasty Related to Surgical Approach: An Analysis of 122,345 Primary Total Hip Arthroplasties.

A number of surgical approaches are available for total hip arthroplasty (THA), but there are limited large-volume, multi-surgeon data comparing the rates of early revisions following these approaches. The aim of this study was to compare the rate of revision of primary conventional THA related to surgical approach. Data from the Australian Orthopaedic Association National Joint Replacement Registry were analyzed for all patients who had undergone a primary THA for osteoarthritis from January 2015 to December 2018. The primary outcome measure was the cumulative percent revision (CPR) for all causes. Secondary outcome measures were major revision (a revision procedure requiring change of the acetabular and/or femoral component) and revision for specific diagnoses: fracture, component loosening, infection, and dislocation. Age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, femoral head size, and femoral fixation were assessed as potential confounders. There was a total of 122,345 primary conventional THAs for which the surgical approach was recorded in the registry; 65,791 were posterior, 24,468 were lateral, and 32,086 were anterior. There was no difference in the overall CPR among approaches, but the anterior approach was associated with a higher rate of major revisions. There were differences among the approaches with regard to the types of revision. When adjusted for age, sex, ASA score, BMI, femoral head size, and femoral fixation, the anterior approach was associated with a higher rate of femoral complications-i.e., revision for periprosthetic fracture and femoral loosening. There was a lower rate of revision for infection after the anterior approach compared with the posterior approach in the entire period, and compared with the lateral approach in the first 3 months. The posterior approach was associated with a higher rate of revision for dislocation compared with both the anterior and the lateral approach in all time periods. The anterior approach was associated with a lower rate of revision compared with the lateral approach in the first 6 months only. There was no difference in the overall early CPR among the surgical approaches, but the anterior approach was associated with a higher rate of early major revisions and femoral complications (revisions for periprosthetic fracture and femoral loosening) compared with the posterior and lateral approaches and with a lower rate of dislocation and infection. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Algorithmic soft tissue femoral release in anterior approach total hip arthroplasty.

Although the anterior approach for total hip arthroplasty has gained increasing utilization, some studies have suggested a higher risk of femoral complications, as well as difficulty with femoral exposure. Techniques of soft tissue releases have been described to offer better femoral exposure, and to help mitigate complications. The purpose of the study is to describe an algorithmic soft tissue femoral release in direct anterior approach total hip arthroplasty and to assess the clinical outcomes of patients upon which this algorithm of femoral soft tissue releases was utilized. Clinical outcomes with the Harris Hip Score, reoperation rates, component survivorship, and complications were analyzed.

P2837Day-case complex left atrial ablation is safe and cost-effective: experience from a UK tertiary centre

Abstract Background Day-case standard catheter ablation is becoming routine. However, patients having complex left atrial ablation for atrial fibrillation (AF) or left atrial tachycardia (LAT) often stay overnight. We have been performing day-case complex left atrial ablation since 2015. Purpose To evaluate the safety, efficacy and cost-effectiveness of day-case complex left atrial ablation compared with those who stayed overnight. Methods A retrospective analysis of all consecutive complex left atrial ablations performed in a UK tertiary cardiac centre between 2010–2018. Data were collected on baseline parameters, procedure details including mapping technique, ablation strategy, immediate efficacy, and acute complications. Results A total of 830 complex left atrial catheter ablations were performed; mean age±SD=60±12 years, 63% male. The majority were AF ablation (n=804, 96.9%), with the rest being LAT/left-atrial flutter. Of the AF cases, 545 were paroxysmal (≤7 days), 212 persistent (&gt;7 days) and 47 long-standing (&gt;1yr); 98% of cases were elective. Pulmonary vein isolation was performed in all; additional LA lines were done in 163, CTI ablation in 129 and CFAEs in 33. 3D-mapping (Carto/Precision)=44.7% (with contact sensing=38.0%), PVAC=18.7%, PVI cryo-balloon=36.6%. Of the cohort 331 (39.9%) were done as day-case. Acute success= 94.9%, acute complications=4.58% (femoral site complications, n=12; pericardial effusion, n=19 (9 needing drain); stroke/cerebral embolus, n=3; phrenic nerve palsy, n=5; first degree heart block, n=1). Comparison of day-case vs non day-case revealed no significant difference in number of complications (Table 1). An overnight stay at out hospital costs £350. During the period of study our institution saved £115.850 (∼140,000 euros). Day-case vs non day-case ablation Parameters Day-case (n=331) Non day-case (n=499) p-value Mean age ± SD (years) 61.2±11.6 59.1±11.9 0.009 Males (n, %) 205 (61.9%) 321 (64.3%) 0.484 Normal heart (n, %) 243 (73.4%) 383 (76.8%) 0.276 Paroxysmal AF (n, %) 218 (65.9%) 327 (65.5%) 0.928 Fluoroscopy time (mins) 23.8±13.9 27.0±14.5 0.001 Procedure time (mins) 150±89.6 163±68.2 0.025 % with 3D-mapping 30.8% 56.9% &lt;0.001 Acute complications (n, %) 12 (3.63%) 26 (5.21%) 0.285 Conclusions Day-case complex left atrial cardiac ablation is safe and effective. It is associated with good clinical outcomes and leads to significant cost savings as an overnight stay is not needed.

Femoral Fixation Methods in Hip Resurfacing Arthroplasty: An 11-Year Retrospective Comparison of 4013 Cases

BackgroundThe optimal femoral fixation method remains unclear. To evaluate the role of femoral fixation techniques in hip resurfacing, we present a comparison of 2 consecutive groups: group 1 (739 hips) with cemented femoral components; group 2 (3274 hips) with uncemented femoral components. MethodsWe retrospectively analyzed our clinical database to compare failures, reoperations, complications, clinical results, and radiographic measurements. Groups were consecutive, so cemented cases had longer follow-up. However, all patients from both groups were at least 2 years out from surgery. Two-year clinical and radiographic data were compared. Longer-term comparison data as well as Kaplan-Meier implant survivorship curves specifically focusing on femoral failure modes were analyzed. ResultsKaplan-Meier 10-year implant survivorship using nontraumatic femoral failure as an end point was 98.9% for the cemented and 100% for the uncemented femoral component. The uncemented, group 2 cases showed a significantly lower raw failure rate (1.1% vs 4.6%), 2-year failure rate (0.8% vs 2.8%), 2-year femoral failure rate (0.4% vs 0.9%), and a lower combined rate of femoral complications and failures (0.6% vs 1.8%). In cases that did not fail, patient mean clinical scores, pain scores, and combined range of motion were all significantly better for group 2. ConclusionWe have demonstrated that in the fully porous-coated ReCap device, uncemented femoral fixation is superior to cemented fixation at 11 years follow-up (0.0% vs 1.1% late femoral loosening) in this single-surgeon cohort. Early femoral fractures also reduced from 0.8% to 0.3%, but this may be partially or completely due to a new bone density management program. This study demonstrates better femoral implant survivorship for the uncemented device compared to the cemented femoral resurfacing component for this implant design.

Abstract TP461: Predictors of Groin Punction Complication After Edovascular Therapies

Background: Endovascular therapies(EVT) have exponentially increased in the last few years. To maximize the benefits of EVT, complications related to the treatment need to be prevented or minimized with early detection and appropriate management. We implemented a specific registry to collect femoral post-puncture complications detected at different timepoints. Our aim was to identify factors associated with severe groin punction complications. Methods: Prospective study of consecutive patients treated with acute EVT or scheduled (angioplasty), admitted to our Stroke Unit from February2017-June2018. Post-catheterization femoral complications included: groin bleeding(GB), groin hematoma(GH), retroperitoneal hematoma(RH), femoral artery pseudoaneurysm(FAP), and artery dissection(AD). A specific registry was created for data collection at different timepoints: During or immediate post-EVT, at 24h post-compression and at discharge. Results: 384patients were treated with EVT(73%acute), mean age 71+/-13y.o, 69% men. Mynxgrip closure system was used in 346(91,8%). Compressive measures needed to be reinforced in 55 cases(14,5%)/changed in 15(4%). Early mobilization protocol(24-48h) was initiated in 335patients(92,3%). 9patients (2,8%) did not maintain the first 24h absolute rest. 57patients(15,1%) presented mild immediate complications(49GH,6GB). At 24h, 181(47,1%)patients presented GH(28,6%superficial, 18,2%internal) and 5GB(1,3%). At discharge, 29(8,1%)patients had presented clinically significant femoral complications: 16GH(13deep), 5FAP, 1AD, 4RH. 2 of those complications were fatal. Variables associated with severe complications at discharge were: age(p=0.037), non-use of mynxgrip(p=0.001), compressive replacement(p&lt;0.001), non-compliance of early mobilization protocol(p=0.014). Conclusion: In our series, we found a yield of 8,1% of clinically significant groin complications associated with the EVT (0,5% fatal). We indentified age, closure device, requirement to replace compressive and lack of accomplishment of the early mobilization protocol as predictors of these complications.

Antegrade flexible intramedullary nailing through the greater trochanter in paediatric femur shaft fractures

Aims: To determine whether an antegrade approach, through the tip of the greater trochanter, in femoral shaft fractures in children, is safe, achieves adequate union and results in significant proximal femoral growth complications. Patients and methods: The case records and radiographs of 23 paediatric patients aged 7 to 12 years with femur shaft fractures managed with stainless steel antegrade flexible nailing were reviewed retrospectively. Pre-operative radiographs were reviewed for fracture pattern, level and comminution. Post-operative radiographs were reviewed to assess for union, alignment, osteonecrosis of the femoral head and epiphysiodesis of the greater trochanter. Morphological changes of the proximal femur were assessed by comparing the neck shaft angle and articulo-trochanteric distance with the opposite hip. Case records were reviewed for post-operative complications, patient-reported complaints and leg length discrepancy. Clinical outcomes were assessed with the criteria established by Flynn. Results: All patients achieved union, and none had evidence of osteonecrosis of the femoral head on follow-up. Three patients had malalignment and two patients had radiographic evidence of greater trochanteric epiphysiodesis. Two patients had morphological changes of the proximal femur, with one having an increased neck shaft angle and one an increased articulo-trochanteric distance. One patient had a leg length discrepancy of 2 cm. Fifteen patients had excellent clinical outcomes, five had satisfactory outcomes and three had poor outcomes according the criteria established by Flynn. Conclusion: Antegrade entry through the tip of the greater trochanter does not appear to compromise the blood supply to the femoral head or increase the risk of clinically significant morphological changes to the proximal femur. All patients achieved adequate union. Furthermore, antegrade insertion avoided skin problems and prominent nail complications around the knee seen with retrograde insertion. Level of evidence: Level 4

Routine use of fluoroscopic guidance and up-front femoral angiography results in reduced femoral complications in patients undergoing coronary angiographic procedures: an observational study using an Interrupted Time-Series analysis.

Transradial access is increasingly used for coronary angiography and percutaneous coronary intervention, however, femoral access remains necessary for numerous procedures, including complex high-risk interventions, structural procedures, and procedures involving mechanical circulatory support. Optimising the safety of this approach is crucial to minimize costly and potentially life-threatening complications. We initiated a quality improvement project recommending routine fluoroscopic guidance (femoral head), and upfront femoral angiography should be performed to assess for location and immediate complications. We assessed the effect of these measures on the rate of vascular complications. Data were collected prospectively on 4534 consecutive patients undergoing femoral coronary angiographic procedures from 2015 to 2017. The primary end-point was any access complication. Outcomes were compared pre and post introduction including the use of an Interrupted Time-Series (ITS) analysis. 1890 patients underwent angiography prior to the introduction of routine fluoroscopy and upfront femoral angiography and 2644 post. All operators adopted these approaches. Baseline characteristics, including large sheath use, anticoagulant use and PCI rates were similar between the 2 groups. Fluoroscopy-enabled punctures were made in the 'safe zone' in over 91% of cases and upfront femoral angiography resulted in management changes i.e. procedural abandonment prior to heparin administration in 21 patients (1.1%). ITS analysis demonstrated evidence of a reduction in femoral complication rates after the introduction of the intervention, which was over and above the existing trend before the introduction (40% decrease RR 0.58; 95% CI: 0.25-0.87; P < 0.01). Overall these quality improvement measures were associated with a significantly lower incidence of access site complications (0.9% vs. 2.0%, P < 0.001). Routine fluoroscopy guided vascular access and upfront femoral angiography prior to anticoagulation leads to lower vascular complication rates. Thus, study shows that femoral intervention can be performed safely with very low access-related complication rates when fluoroscopic guidance and upfront angiography is used to obtain femoral arterial access.

Direct Anterior Approach and Perioperative Fracture With a Single-Taper Wedge Femoral Component

BackgroundDespite growing interest in direct anterior approach total hip arthroplasty, perioperative femoral fracture and early aseptic loosening are increasingly recognized complications. Previous research has documented the role of surgeon experience in association with these femoral complications. The purpose of this study was to explore the relationship between femoral component design and early periprosthetic femoral complications. MethodsThis was an extension of previous work with an updated patient cohort of 5090 consecutive direct anterior primary total hip arthroplasties at a single institution with a single-taper, wedge femoral stem comprising 4 variants involving length and geometry: group 1, full-length, standard profile; group 2, full-length, reduced distal profile; group 3, short-length, standard profile; and group 4, short-length, reduced distal profile. Records were reviewed retrospectively for the incidence of early postoperative periprosthetic fracture or aseptic loosening and analyzed with regard to patient demographics and femoral stem type. ResultsThere were 42 (0.83%) periprosthetic femur complications observed in the early postoperative period. Increased age (P < .001) and female gender (P = .023) were significantly associated with incidence of femoral complications in univariate analysis, while age maintained this significant relationship in multivariate analysis (P < .001). There was a trend toward increased complication rate in patients receiving a short stem with full profile taper (1.27%, P = .0539). ConclusionDespite an overall low rate of femoral complications after direct anterior total hip arthroplasty, the risk is increased in elderly patients and females. Furthermore, femoral stem design may portend an elevated risk of these complications.