Total Hip Arthroplasty For Fracture Research Articles

Incidence of Ceramic Component Fractures in Total Hip Arthroplasty Using Contemporary Ceramic-On-Ceramic Bearings: A Retrospective Study Spanning Two Decades From Two Tertiary Referral Hospitals

IntroductionCeramic-on-ceramic (CoC) bearings have been widely used in total hip arthroplasty (THA) due to their excellent wear properties. However, ceramic component fractures remain a concern. This study aimed to report the incidence of third- and fourth-generation ceramic component fracture and identify factors that might influence this complication. MethodsA total of 9,280 hips that underwent THA with third- and fourth-generation CoC bearings at two tertiary institutions between 1997 and 2023 were retrospectively reviewed, and the incidence and associated factors of CoC bearing fracture were determined. We performed a Kaplan–Meier survival analysis to assess implant survivorship. Logistic regression was applied to evaluate the influence of implant size and patient-specific factors on the risk of revision. ResultsOut of the 9,280 THA procedures, there were 33 (0.36%) revisions for CoC bearing fracture. Specifically, revisions for fracture were performed for zero out of 6,654 fourth-generation CoC heads, 26 (0.990%) of 2,626 third-generation CoC heads, two (0.030%) of 6,654 fourth-generation CoC liners, and five (0.190%) of 2,626 third-generation CoC liners. All ceramic head fractures occurred in a 28 mm head. Younger age was related to both ceramic head and liner fracture. ConclusionsTo our knowledge, this is the largest two-center retrospective study on CoC bearing fractures to date. The risk of revision for fracture of CoC bearings is low, as previously reported. Our data were comparable to recent evidence suggesting that the latest generation of ceramic components can significantly decrease the incidence of head fracture but not liner fracture. Factors such as younger age and men may be associated with an increased risk of ceramic component fractures. Level of evidenceIII, therapeutic.

Management of Intraoperative Acetabular Fractures in Total Hip Arthroplasty: A Current Concept Review.

Intraoperative acetabular fractures (IAFs), a complication seldomly encountered in total hip arthroplasty, are typically a result of the impact of insertion of a cementless press-fit cup. Factors that contribute to the risk of these types of fractures include poor bone quality, highly sclerotic bone, and the use of a press-fit cup that is excessively large. The approach to management of these fractures is dependent on when they are identified. Immediate stabilization measures should be implemented for management of fractures detected during surgery. When fractures are detected postoperatively, the decision regarding conservative treatment is dependent on the stability of the implant and the specific fracture pattern. In the majority of cases, effective treatment of an acetabular fracture detected intraoperatively can be administered using a multi-hole revision cup along with anchoring screws in the various regions of the acetabulum. Selection of plate osteosynthesis of the posterior column is recommended when there is a large posterior wall fragment or pelvic discontinuity. In cases where anatomical dimensions allow, cup-cage reconstruction may offer a promising alternative to a combined hip procedure. The number of reports addressing the management of IAFs is limited. This review focuses on outlining the strategies that are currently available for management of this seldomly encountered complication.

Ipsilateral pubic ramus fracture during total hip arthroplasty is not rare: does it matter?

IntroductionPeriprosthetic fractures in total hip arthroplasty (THA) have been well described and studied. However, there is a lack of reports on ipsilateral pubic ramus fractures during THA due to the rare occurrence of such fractures and ambiguity of symptoms. With the use of postoperative computed tomography (CT) examinations, we have identified that asymptomatic ipsilateral pubic ramus fractures occur frequently during THA. This study aims to evaluate the incidence, location, clinical outcomes, and risk factors of ipsilateral pubic ramus fractures during THA.MethodsFrom May 2022 to March 2023, a single surgeon performed 203 THAs in 183 patients at a single institution. All patients underwent postoperative CT scans three days after THA. The patients with ipsilateral pubic ramus fractures were followed up for a minimum of six months. Basic demographics, osteoporosis, general conditions of the operations, and outcomes of THA were investigated in all patients.ResultsTwenty-two cases (10.8%) of ipsilateral pubic ramus fractures were identified on postoperative CT scans. All fractures were located near the origin of the superior or inferior pubic ramus. Five fractures were detected on simple postoperative radiographs. The fractures did not cause any further complications at a minimum of six-month postoperative follow-up. Univariate and multivariate analyses did not identify any risk factors associated with these fractures.ConclusionsAlthough the incidence of ipsilateral pubic ramus fractures during THA is high, treatment is not required as they do not cause any significant clinical symptoms or affect the prognosis of THA. However, the possibility of occurrence of these fractures must be explained to the patients before surgery.

Periprosthetic Femoral Fractures in Total Hip Arthroplasty

Objective: This study aimed to analyze the occurrence of periprosthetic fractures (PPFs) in patients who underwent total hip arthroplasty. Methods: The researchers conducted a retrospective review of 447 patients (494 hips) who received a hip replacement with an ESOP stem. The average follow-up period was 12.33 ± 5.2 years. The study population comprised 248 men with 276 hips and 203 women with 220 hips, with a mean age of 65.7 ± 11.6 years. Results: We found 42 PPFs, 15 of them taking place intraoperatively. Regarding the postoperative fractures, 3 of them happened during the first month and the rest of them afterward. There were 3 deaths directly related to the PPF episode. We found a higher risk of fractures among the female, population older than 65 years, and among those with total hip arthroplasty following hip fracture. This population showed a higher incidence of complications and mortality rate. The cumulative percentage probability of periprosthetic femoral fracture was 3.2% (95% confidence interval, 2-5.6) at 10 years, and 10.3% (95% confidence interval, 7-20) at 20 years after surgery. Conclusions: Our findings indicate that periprosthetic femoral fracture incidence increases significantly after the first decade. The use of modular stems did not modify this behavior, similar to other nonmodular or anatomical stems.

Do Cementless, Collared Stems Prevent Aseptic Loosening, Subsidence and Periprosthetic Fracture in Total Hip Arthroplasty?

Do Cementless, Collared Stems Prevent Aseptic Loosening, Subsidence and Periprosthetic Fracture in Total Hip Arthroplasty?

Ceramic-on-Ceramic or Metal-on-Polyethylene: The Bearing of Choice after Ceramic Component Fracture in Total Hip Arthroplasty along with Concise Follow-Up of the Previous Cohort.

We previously reported the questionable result of reoperation using metal-on-polyethylene (MoP) bearing after the fracture of the ceramic component. After the report, we abandoned the use of MoP; instead, we used ceramic-on-ceramic (CoC) bearing. This report aimed to present the outcome of reoperation to CoC bearing after ceramic component failures along with the longer-term outcome of the previously reported cohort with an MoP bearing. The mean follow-up of the MoP cohort was extended from 4.3 years to 8.8 years. Metallosis had occurred in three of nine patients of the previous cohort, which all required re-reoperations. Two hips from 11 patients with revision to CoC had re-reoperations due to ceramic liner fracture and non-union of the osteotomized fragment, respectively. No metallosis and wear occurred in the cohort revised with CoC articulation. Otherwise, there were no adverse changes in radiographs and no impairment in functions. We conducted an extended prospective evaluation of a previous cohort consisting of six head fractures and three liner fractures. In this cohort, the patients underwent a bearing change to metal-on-polyethylene. Additionally, we retrospectively analyzed 11 cases of third-generation ceramic bearing fractures, comprising nine head fractures and two liner fractures. These cases were subsequently treated with a bearing change to fourth-generation CoC. We assessed clinical and radiological outcomes, including complication rates, in both groups. We recommend the latest CoC as the bearing of choice in reoperation after the fracture of ceramic components. In the case of an MoP bearing after the ceramic component fracture, the risk of metallosis seemed high in the early postoperative period.

Monoblock tapered stems in management of UCS B2 and B3 periprosthetic fractures in revision total hip arthroplasty.

United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures. A retrospective review was conducted of all patients who underwent revision THA (rTHA) for periprosthetic UCS B2 and B3 periprosthetic fracture who received a single design monoblock fluted tapered titanium stem at two large, tertiary care, academic hospitals. A total of 72 patients met inclusion and exclusion criteria (68 UCS B2, and four UCS B3 fractures). Primary outcomes of interest were radiological stem subsidence (> 5 mm), radiological osseointegration, and fracture union. Sub-analysis was also done for 46 patients with minimum one-year follow-up. For the total cohort, stem osseointegration, fracture union, and stem subsidence were 98.6%, 98.6%, and 6.9%, respectively, at latest follow-up (mean follow-up 27.0 months (SD 22.4)). For patients with minimum one-year of follow-up, stem osseointegration, fracture union, and stem subsidence were 97.8%, 97.8%, and 6.5%, respectively. Monoblock fluted stems can be an acceptable modality for the management of UCS B2 periprosthetic fractures in rTHAs due to high rates of stem osseointegration and survival, and the low rates of stem subsidence, and revision. Further research on the use of this stem for UCS B3 periprosthetic fractures is warranted to determine if the same conclusion can be made for this fracture pattern.

Hip & Pelvis

The August 2023 Hip & Pelvis Roundup360 looks at: Using machine learning to predict venous thromboembolism and major bleeding events following total joint arthroplasty; Antibiotic length in revision total hip arthroplasty; Preoperative colonization and worse outcomes; Short stem cemented total hip arthroplasty; What are the outcomes of one- versus two-stage revisions in the UK?; To cement or not to cement? The best approach in hemiarthroplasty; Similar re-revisions in cemented and cementless femoral revisions for periprosthetic femoral fractures in total hip arthroplasty; Are hip precautions still needed?

High revision rates and mortality after distal femoral replacement for periprosthetic distal femoral fractures: analysis from the German Arthroplasty Registry (EPRD)

PurposeThis study was initiated to analyze the outcome after distal femoral replacement (DFR) for periprosthetic distal femoral fractures (PDFF).MethodsData from the German Arthroplasty Registry (EPRD) were analyzed. A total of 626 patients could be identified with a DFR for PDFF. Mean age was 78.8 years, and 84.2% were female. Revisions and mortality were analyzed and compared with patient groups with a similar procedure (revision total knee arthroplasty) or similar general condition (fracture total hip arthroplasty, hip hemiarthroplasty). Matched-pair-analyses were performed.ResultsWithin one year after surgery, 13.2% of the patients had died and further 9.4% were revised. Within four years, 32.7% had died and 19.7% were revised. Revisions were nearly twice as high as in the comparison groups. Periprosthetic infection (PJI) was the most frequent cause for revision, resulting in a PJI rate of 12.8%, which was lower in the comparison groups. Mortality after DFR was as similar high as after fracture hip arthroplasty.ConclusionPDFF are a serious injury, and the necessary surgical treatment has a high risk of complications. Every third patient after DFR for PDFF had died and every fifth patient needed revision within 4 years after surgery. Efforts should be undertaken to provide optimal treatment to these high-risk patients to reduce unfavorable outcomes.Level of evidenceIII.Registration of clinical trialsAs this is a registry-derived study of data of the German Arthroplasty Registry (EPRD), no registration was performed.

Similar revision rate after cemented and cementless femoral revisions for periprosthetic femoral fractures in total hip arthroplasty: analysis of 1,879 revision hip arthroplasties in the Dutch Arthroplasty Register

Periprosthetic femoral fracture (PPF) after total hip arthroplasty (THA) is a serious complication, as it often is followed by functional deficits and morbidity. There is no consensus regarding the optimal stem fixation method and whether additional cup replacement is beneficial. The aim of our study was to perform a direct comparison of reasons and risk of re-revision between cemented and uncemented revision THAs following PPF using registry data. 1,879 patients registered in the Dutch Arthroplasty Registry (LROI) who underwent a first-time revision for PPF between 2007 and 2021 (cemented stem: n = 555; uncemented stem: n = 1,324) were included. Competing risk survival analysis and multivariable Cox proportional hazard analyses were performed. 5- and 10-year crude cumulative incidence of re-revision following revision for PPF was similar between cemented (resp. 13%, 95% CI 10-16 and 18%, CI 13-24) and uncemented (resp. 11%, CI 10-13 and 13%, CI 11-16) revisions. Multivariable Cox regression analysis, adjusting for potential confounders, showed a similar risk of revision for uncemented and cemented revision stems. Finally, we found no difference in risk of re-revision between a total revision (HR 1.2, 0.6-2.1) compared with a stem revision. We found no difference in the risk of re-revision between cemented and uncemented revision stems after revision for PPF.

Evaluation of FRAX in patients with periprosthetic fractures following primary total hip and knee arthroplasty

The fracture risk assessment tool (FRAX) is a tool which calculates an individual 10-year fracture risk based on epidemiological data in patients with a risk of osteporosis. The aim of this study was to evaluate the value of FRAX to estimate the risk of postoperative periprosthetic fractures (PPF) in patients following with total hip and knee arthroplasty. 167 patients (137 periprosthetic fractures in total hip arthroplasty and 30 periprosthetic fractures in total knee arthroplasty) were included in this study. Patients’ data was retrieved retrospectively. In each patient the 10-year probability of a major osteoporotic fracture (MOF) and an osteoporotic hip fracture (HF) was calculated using FRAX. According to the NOGG guideline 57% of total hip arthroplasty (THA) patients and 43.3% of total knee arthroplasty (TKA) patients were in need of osteoporosis treatment, whereas only 8% and 7% received an adequate one respectively. 56% of the patients with PPF after THA and 57% of the patients with PPF after TKA reported about a previous fracture. Significant associations between the 10-year probability of a MOF and HF calculated by FRAX and PPF in THA and TKA were seen. The results of the present study show that FRAX might have the potential to estimate the PPF in patients following THA and TKA. FRAX should be calculated before and after THA or TKA in order to assess the risk and counsel patients. The data show a clear undertreatment of patients with PPF in respect to osteoporosis.

Undetected Intraoperative Periprosthetic Femoral Fractures in Patients Undergoing Primary Total Hip Arthroplasty: A Retrospective Case Series and Literature Review.

Periprosthetic fracture in total hip arthroplasty (THA) can be catastrophic, and early detection and appropriate management are vital to the overall prognosis. This study aimed to describe and summarize the features of undetected intraoperative periprosthetic femoral fractures (IPFFs) in primary THA patients and treatment measures and to review the relevant literature. We reviewed a total of 6350 primary THAs performed at our institution between January 2013 and December 2020 and screened all IPFFs. Of 138 IPFFs, 24 were undetected and met the inclusion criteria. We recorded and compared basic patient and operative information and measured some parameters to evaluate canal morphologies based on preoperative radiographs. We also compared fracture line characteristics using postoperative radiographs to summarize the features of intraoperative fractures and propose treatment strategies. The Kolmogorov-Smirnov test was used to test the normality of the variable distributions. Measured parameters in all groups were analyzed using one-way analysis of variance and compared using Dunnett's test. The χ2 and Fisher exact tests were used to compare reoperation rates across the groups. Interrater and intrarater reliability were evaluated by intraclass correlation coefficients. Among the 24 hips, there was no significant difference in patient demographics, basic operative information or morphology. The incidence of IPFFs in primary THA patients was 2.17%, and up to 17.4% of IPFFs were undetected until postoperative fluoroscopy. The incidence of undetected IPFFs among all primary THA patients was 0.38% and varied by stem type, with the highest incidence in femurs with either anatomical (1.04%, 4/385) or modular stems (0.90%, 9/1003). Femurs with anatomical stems had a higher reoperation rate. The distal periprosthetic (Gruen zone 4) fracture line of femurs with tapered stems was more prone to involve the medial or lateral bone cortex, which could cause instability. An undetected IPFF is most likely in femurs fitted with a prosthesis of an inappropriate size or type. Anatomical stems will most likely cause unstable fractures; thus, it is recommended to use them with caution and note the possibility of medial distal femoral fracture. Improper modular stem type or size selection results in longitudinal fractures of the distal femur, and prophylactic cerclage wire binding is recommended in dysplastic hips. Incorrect use of tapered stems in well-ossified femurs may cause distal femoral fractures involving the medial or lateral bone cortex. Intraoperative fluoroscopy after implantation may help detect hidden fractures.

Preoperative Malnutrition and Metabolic Markers May Predict Periprosthetic Fractures in Total Hip Arthroplasty

BackgroundPeriprosthetic fractures are a devastating complication of total hip arthroplasty (THA) and are associated with significantly higher mortality rates in the postoperative period. Given the strain that periprosthetic fractures place on the patient as well as the healthcare system, identifying and optimizing medical comorbidities is essential in reducing complications and improving outcomes. MethodsAll THA with primary indications of osteoarthritis from 2007 to 2020 were queried from the National Surgical Quality Improvement Program database. Demographic data, preoperative laboratory values, medical comorbidities, hospital course, and acute complications were collected and compared between patients with and without readmission for a periprosthetic fracture. A multivariate logistic regression analysis was performed to determine associated independent risk factors for periprosthetic fractures after index THA. ResultsThe analysis included 275,107 patients, of which 2539 patients were readmitted for periprosthetic fractures. Patients with postoperative fractures were more likely to be older (>65 years), females, BMI >40, and increased medical comorbidities. Preoperative hypoalbuminemia, hyponatremia, and abnormal estimated glomerular filtration rates were independent risk factors for sustaining a periprosthetic fracture and readmission within 30 days. Modifiable patient-related factors of concurrent smoking and chronic steroid use at the time of index THA were also independent risk factors for periprosthetic fractures. Inpatient metrics of longer length of stay, operative time, and discharge to rehab predicted postarthroplasty fracture risk. Readmitted fracture patients subsequently had increased risks of developing a surgical site infection, urinary tract infection, and requiring blood transfusions. ConclusionsPatients with hypoalbuminemia, hyponatremia, and abnormal estimated glomerular filtration rate are at increased risk for sustaining periprosthetic fractures after THA. Preoperative optimization with close monitoring of metabolic markers and modifiable risk factors may help not only prevent acute periprosthetic fractures but also associated infection and bleeding risk with fracture readmission.

Treatment options for proximal periprosthetic femoral fractures in Total Hip Arthroplasty: a single center experience.

Proximal periprosthetic femoral fractures (PPFFs) are gradually increasing and surgical management is often associated with high risk of complications, due to elderly population and associated comorbidities. We retrospectively assessed 39 patients at least at 2-years follow-up. We identified two study groups, similar for demographic data. Group A included patients surgically treated without involving prosthetic implants, whereas Group B included patients in which an implant revision was performed. Data were recorded from January 2017 to February 2020, and 39 patients were included: 30 females (76.9%) and 9 males (23.1%), with a confirmed diagnosis of periprosthetic fracture of the proximal femur. 23 (58.9%) patients were treated with Open Reduction and Internal Fixation (ORIF), 12 (30.7%) with revision surgery and 4 (10.3%) were treated by modular megaprosthesis. The treatment options considered in the study, revision arthroplasty and internal fixation had shown no significant differences as a matter of clinical outcomes and postoperative complications.

Ceramic Liner Fracture in Total Hip Arthroplasty: A Case Report

Background. Ceramic component fracture is a severe complication of primary and revision total hip arthroplasty, leading to multiple revision surgeries.
 Case report. This report of rare clinical case of ceramic liner fracture. Fifteen months after a planned left hip replacement, the patient experienced anterior surface pain in the area of the operated joint accompanied by creaking, so the patient went for a consultation. Based on the results of the consultation, the patient was urgently hospitalized and underwent a delayed surgery for revision arthroplasty. Radiologically, there was varus position of the femoral component, dislocation of the bearings. MSCT showed ceramic liner fracture and fragment dislocation. Intraoperatively, the multifragmentary fracture of the liner, significant damage to the head, and retroversion of the acetabular component (retroversion was detected on the preoperative CT scan) were identified. All components of the endoprosthesis and tribologic bearings were replaced with identical ones, total synovectomy was performed, and the wound was cleaned and sanitized.
 Conclusion. The presented case report demonstrates the danger of incorrect positioning of the components when using a ceramic bearings. In this case, retroversion of the acetabular component and varus position of the femoral component resulted in a reduced contact area between the head and the liner, which caused the ceramic to fracture. The described observation confirms the need for further in-depth study of the ceramic bearings in order to prevent ceramic component fracture, as it leads to severe complications and significant economic costs.

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

BackgroundOsteopetrosis 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. MethodsPatients 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. ResultsThe 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. ConclusionPatients 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.

Worsening Arthroplasty Utilization With Widening Racial Variance During the COVID-19 Pandemic

BackgroundElective arthroplasty surgery in the United States came to a near-complete halt in the spring of 2019 as a response to the COVID-19 pandemic. Racial disparity has been a long-term concern in healthcare with increased focus during the pandemic. The purpose of this study is to evaluate the effects of COVID-19 and race on arthroplasty utilization trends during the pandemic. MethodsWe used 2019 and 2020 Center for Medicare and Medicaid Service fee-for-service claims data to compare arthroplasty volumes prior to and during the COVID-19 pandemic. We compared overall arthroplasty utilization rates between 2019 and 2020 and then sought to determine the effect of race and COVID-19, both independently and combined. ResultsThere was a decrease in primary total knee arthroplasty (−28%), primary total hip arthroplasty (−14%), primary total hip arthroplasty for fracture (−2%), and revision arthroplasty (−14%) utilization between 2019 and 2020. The highest decrease in overall arthroplasty utilization was in the Hispanic population (34% decrease vs 19% decrease in the White population). We found that a non-White patient was 39.9% (P < .001) less likely to receive a total joint arthroplasty prior to COVID-19. The COVID-19 pandemic further exacerbated the pre-existing racial differences in arthroplasty utilization by decreasing the probability of receiving a total joint arthroplasty for non-White patient by another 12.9% (P < .001). ConclusionWe found an overall decreased utilization rate of arthroplasty during the COVID-19 pandemic with further decrease noted in all non-White populations. This raises significant concern for worsening racial disparity in arthroplasty caused by the ongoing pandemic.

Periprosthetic femoral fractures in Total Hip Arthroplasty (THA): a comparison between osteosynthesis and revision in a retrospective cohort study

BackgroundPeriprosthetic femoral fractures are challenging complications of hip arthroplasty. They are supposed to be a rare complication, but their incidence is rapidly increasing. Surgical treatment aims to achieve early mobilization and avoid the complications of prolonged bed rest. Aim of this study is to evaluate the clinical outcomes of surgical treatment comparing two surgical approaches: revision arthroplasty (RA) versus open reduction and internal fixation (ORIF).MethodsAuthors retrospectively reviewed a series of 117 patients with total hip arthroplasty treated for periprosthetic femur fractures in the period between January 2013 and March 2018 at a single tertiary referral center. Of these, 70 patients satisfied strict inclusion criteria. Patients were classified according to the Unified Classification System (UCS) and distributed in two groups according to surgical treatment. Clinical outcomes were assessed using the Oxford Hip recorded preoperatively and post operatively, Barthel Score, CIRS score (Cumulative illness rating scale), type of fracture and post-operative complications with a minimum follow up of 1 year.ResultsNominal univariate statistical analysis revealed significant differences between the post and pre-operative Oxford Hip Score (Δ Oxford) and the surgical treatment (p = 0.008) and CIRS score (p = 0.048). Moreover, we observed a significant relationship between type of treatment and type of fracture (p = 0.0001). Multivariate analyses revealed that CIRS score was independently associated with Oxford Score improvement after surgery (p = 0.024).ConclusionsData from this case series confirmed that surgical treatment was correlated to type of fracture, according to UCS classification. Patients treated by RA had a better functional outcome than patients treated with ORIF, but these results are strongly influenced from the patients’ age, Barthel index and CIRS score. Also, authors found a correlation between functional outcome and comorbidities evaluated by CIRS score. Based on these data we suggest a multimodal approach to these patients, like those used for proximal femoral fractures.

A Proposition to Standardize the Microstructural Grain Size Measurements of Hip Stems

Abstract Femoral stem fractures in total hip arthroplasty (THA) are a problem in clinical practice that results in great morbidity and high cost of revision hip surgery. Stem fractures are multifactorial events that are usually related to a combination of factors that increase the mechanical stress on the stem or decrease the mechanical strength of the implant. Failure analyses of hip prosthesis have identified that the presence of inadequate grain size may lead to implant failure. The aim of this article is to develop a rational to set specific sites to perform grain size measurements along stems used in THA as well as appropriate procedures to evaluate the heterogeneity of the microstructure related to the grain size distribution. In the present study, nonmodular femoral stems from three manufacturers with different wrought materials were chosen: stainless steel ISO 5832-1 (Manufacturer I), high nitrogen stainless steel ISO 5832-9 (Manufacturer II), and cobalt-chromium-molybdenum alloy ISO 5832-12 (Manufacturer III). The results of this study showed a great variability of grain size number depending on the cross section and fields evaluated. Therefore, the current technical standards for evaluating THA stems need to be modified. Analyses of grain sizes at different cross sections and inside each cross section of the stem is necessary to ensure the safety of hip stems.

Periprosthetic fractures of the femur in primary total hip arthroplasty: a New Zealand Joint Registry analysis.

Periprosthetic femoral fractures around total hip arthroplasty (THA) are increasing annually, and are a major cause for revision surgery in the New Zealand Joint Registry (NZJR). The aim of this study was to determine the timing and risk factors for periprosthetic femoral fractures in THA requiring revision surgery in the NZJR. All patients with a primary THA who sustained a periprosthetic femoral fracture requiring revision THA recorded in the NZJR were reviewed to determine age, gender, body mass index, American Society of Anesthesiologists (ASA) rating and femoral stem fixation (cemented or uncemented). Revision rates were calculated per 100 component years (cy), and risk factors determined in the first 90 days, and beyond. Between 1999 and 2017, there were 713 revision THA for periprosthetic femoral fractures. Early revision THA was significantly associated with ASA score and body mass index ≥40. There was no gender difference (P = 0.274). The revision rate in uncemented femoral stems (1.12/100 cy) was significantly higher (p < 0.001) than cemented stems (0.16/100 cy). After 90 days, the revision rate was significantly higher with increasing age (P < 0.001), males (P < 0.001) and higher ASA score (P < 0.001). The difference between cemented (0.07/100 cy) and uncemented (0.05/100 cy) stems did not reach statistical significance (P = 0.108). The rate of revision THA for periprosthetic femoral fracture is higher in uncemented femoral stems in the first 90 days, and is significantly associated with ASA score and morbid obesity. After 90 days, the rate is lower for uncemented femoral stems, but did not reach statistical significance.