Higher Risk Of Periprosthetic Fracture Research Articles

Revisiting Cemented Femoral Fixation in Hip Arthroplasty.

The primary means of femoral fixation in North America is cementless, and its use is increasing worldwide, despite registry data and recent studies showing a higher risk of periprosthetic fracture and early revision in elderly patients managed with such fixation than in those who have cemented femoral fixation. Cemented femoral stems have excellent long-term outcomes and a continued role, particularly in elderly patients. Contrary to historical concerns, recent studies have not shown an increased risk of death with cemented femoral fixation. The choice of femoral fixation method should be determined by the patient's age, comorbidities, and bone quality. We recommend considering cemented femoral fixation in patients who are >70 years old (particularly women), in those with Dorr type-C bone or a history of osteoporosis or fragility fractures, or when intraoperative broach stability cannot be obtained.

CORR Insights®: No Difference in Functional, Radiographic, and Survivorship Outcomes Between Direct Anterior or Posterior Approach THA: 5-Year Results of a Randomized Trial.

CORR Insights®: No Difference in Functional, Radiographic, and Survivorship Outcomes Between Direct Anterior or Posterior Approach THA: 5-Year Results of a Randomized Trial.

The association between bisphosphonate use and aseptic revision risk in primary elective shoulder arthroplasty

BackgroundThe total joint literature has shown promising results of bisphosphonate use on decreasing early bone loss after hip and knee arthroplasty and reducing aseptic revision risk though a higher risk of periprosthetic fracture has also been reported. We sought to evaluate the association between bisphosphonate use and aseptic revision risk in patients undergoing shoulder arthroplasty. MethodsA US integrated healthcare system's registry was used to identify 6204 patients who underwent primary elective shoulder arthroplasty for osteoarthritis (2005-2016). Preoperative bisphosphonate users (defined as having at ≥6-month supply and 80% adherence) were compared to nonbisphosphonate users. Multivariable Cox proportional hazard regression was used to evaluate aseptic revision risk according to bisphosphonate use while adjusting for confounders. Secondary analysis stratified by age (40-64, ≥65 years) and bone quality status (normal, osteopenia, osteoporosis, or unknown). ResultsAt the time of index procedure, 564 (9.1%) were considered as bisphosphonate users. We failed to observe a difference in aseptic revision risk by bisphosphonate use (hazard ratio = 0.92, 95% confidence interval = 0.50-1.72). No association was observed even after stratifying by bone quality and age. No revisions for periprosthetic fracture occurred in the bisphosphonate user group during follow-up. ConclusionsWhile prior studies in lower extremity joint arthroplasty cohorts have observed a differential risk for revision surgery with bisphosphonate use, we failed to observe any associations between bisphosphonate use and revision risk in a cohort of shoulder arthroplasty patients. Level of EvidenceLevel III; Retrospective Cohort Comparative Study

Short single-wedge stems have higher risk of periprosthetic fracture than other cementless stem designs in Dorr type A femurs: a finite element analysis.

The use of total hip arthroplasty (THA) femoral stems that transmit force in a favourable manner to the femur may minimise periprosthetic fractures. Finite element analysis (FEA) is a computerised method that analyses the effect of forces applied to a structure with complex shape. Our aim was to apply FEA to compare primary THA cementless stem designs and their association with periprosthetic fracture risk. 3-dimensional (3D) models of a Dorr Type A femur and 5 commonly used primary THA cementless stem designs (short single wedge, standard-length single wedge, modular, double-wedge metaphyseal filling, and cylindrical fully coated) were developed using computed tomography (CT) imaging. Implant insertion, single-leg stance, and twisting with a planted foot were simulated. FEA was performed, and maximum femoral strain along the implant-bone interface recorded. Femoral strain was highest with short single-wedge stem design (0.3850) and lowest with standard-length single-wedge design (0.0520). Location of maximum femoral strain varied by stem design, but not with implant insertion, single-leg stance, or twisting with a planted foot. Strain was as high during implant insertion as with single-leg stance or twisting with a planted foot. Our results suggest the risk of intraoperative and postoperative periprosthetic fracture with THA in a Dorr A femur is highest with short single-wedge stems and lowest with standard-length single-wedge stems. Consideration may be given to minimising the use of short single-wedge stems in THA. Implant-specific sites of highest strain should be carefully inspected for fracture.

An Update on Cementless Femoral Fixation in Total Hip Arthroplasty.

➤ Cementless stems can be categorized using the updated classification system.➤ Short stems were designed as an alternative to conventional stems with the advantage of bone preservation, and they have grown in popularity with promising results; however, long-term outcomes are lacking.➤ Hydroxyapatite coating appears to have no advantage with respect to stem loosening.➤ The literature has shown no difference in revision rates between modular and nonmodular stems; however, with the advantages of equalizing limb lengths and offset come the drawbacks of corrosion and junctional fatigue failure of modular implants.➤ There is increasing use of cementless stems, including in octogenarians, with promising outcomes compared with cemented stems; however, there is a higher risk of periprosthetic fractures with cementless fixation, particularly in elderly female patients.

More reoperations for periprosthetic fracture after cemented hemiarthroplasty with polished taper-slip stems than after anatomical and straight stems in the treatment of hip fractures: a study from the Norwegian Hip Fracture Register 2005 to 2016.

The aim of this large registry-based study was to compare mid-term survival rates of cemented femoral stems of different designs used in hemiarthroplasty for a fracture of the femoral neck. From the Norwegian Hip Fracture Register (NHFR), 20 532 primary cemented bipolar hemiarthroplasties, which were undertaken in patients aged > 70 years with a femoral neck fracture between 2005 and 2016, were included. Polished tapered stems (n = 12 065) (Exeter and CPT), straight stems (n = 5545) (Charnley, Charnley Modular, and Spectron EF), and anatomical stems (n = 2922) (Lubinus SP2) were included. The survival of the implant with any reoperation as the endpoint was calculated using the Kaplan-Meier method and hazard ratios (HRs), and the different indications for reoperation were calculated using Cox regression analysis. The one-year survival was 96.0% (95% confidence interval (CI) 95.6 to 96.4) for the Exeter stem, 97.0% (95% CI 96.4 to 97.6) for the Lubinus SP2 stem, 97.6% (95% CI 97.0 to 98.2) for the Charnley stem, 98.1% (95% CI 97.3 to 98.9) for the Spectron EF stem, and 96.4% (95% CI 95.6 to 97.2) for the Charnley Modular stem, respectively. The hazard ratio for reoperation after one year was lower for Lubinus SP2 (HR 0.77, 95% CI 0.60 to 0.97), Charnley (HR 0.64, 95% CI 0.48 to 0.86), and Spectron EF stems (HR 0.44, 95% CI 0.29 to 0.67) compared with the Exeter stem. Reoperation for periprosthetic fracture occurred almost exclusively after the use of polished tapered stems. We were able to confirm that implant survival after cemented hemiarthroplasty for a hip fracture is high. Differences in rates of reoperation seem to favour anatomical and straight stems compared with polished tapered stems, which had a higher risk of periprosthetic fracture.

Polished, Collarless, Tapered, Cemented Stems for Primary Hip Arthroplasty May Exhibit High Rate of Periprosthetic Fracture at Short-Term Follow-Up

BackgroundCemented stems are designed to follow 1 of 2 principles of fixation: composite beams or slide taper. Stems in the latter category have a collarless, polished, tapered (CPT) design and subside into the cement mantle, creating hoop stresses. We compared the rate of periprosthetic fracture (PPF) of stem designed with these 2 principles of fixation. In addition, we examined radiographic factors that may predispose to the development of PPF. MethodsWe retrospectively reviewed all patients who underwent primary THA by a single surgeon using highly polished cemented stems. PPF rates were compared between CPT stems (follow-up, 21 months; standard deviation [SD], 22) and composite beam stems (follow-up, 21.7 months; SD, 26). Demographic data were compared between patients with and without a PPF. Three preoperative radiographic parameters (canal bone ratio [CBR], canal-calcar ratio, and canal flare index), stem alignment, and cement mantle were compared in match-paired patients with and without a PPF (1:34). ResultsSeven of 1460 THA patients developed a PPF (0.479%); 4 hips of 185 with a CPT stem (2.2%); and 3 of 1275 hips with a composite beam stem (0.23%; P = .0064). Three of the 4 PPFs in the CPT group and none in the composite beam group were classified as Vancouver B2. The CBR in patients with a PPF was 0.50 (SD, 0.07) and 0.43 (SD, 0.07) in the match cohort of hips without PPF (P = .013). ConclusionCPT stems may be associated with a higher risk of PPF that often require reoperation. An increased CBR may be a risk factor for postoperative PPF.

What Are the Preoperative Outcome Measures That Predispose to Periprosthetic Fractures After Primary Total Knee Arthroplasty?

BackgroundThere is little known in the literature about whether preoperative patient-reported outcome measures (PROMs) would affect the risk of periprosthetic fractures (PPFs) after primary total knee arthroplasty (TKA). Our study aims to evaluate the predictive values of PROMs on PPF after primary TKA. We hypothesize that poorer PROMs are associated with a higher risk of PPF after primary TKA. MethodsWe reviewed prospectively collected data in our hospital arthroplasty registry. Patients who sustained PPF after primary TKA between 2000 and 2015 were identified. Forty-two patients were identified and matched for gender, age, and body mass index to a control group of 84 patients who had primary TKA without PPF in a 2:1 ratio. Preoperative demographics, Short Form-36 (SF-36) scores, Oxford Knee score and Knee Society Score were evaluated. Variables of PROMs were entered into a multivariate logistic regression model. A variable was considered to be a significant predictor if its odds ratio was significant at P < .05. ResultsAfter multivariate regression analysis, SF-36 subdomains of physical functioning (PF) and vitality (VT) were identified as significant predictors for PPFs after primary TKA. A lower SF-36 PF and VT scores were associated with higher risks of sustaining a PPF after primary TKA. ConclusionFrom our study, low preoperative SF-36 PF and VT scores are associated with a higher risk of PPFs after primary TKA. These results can allow the preoperative identification of patients at higher risk of PPF, and appropriate preoperative counseling, optimization, and close follow-up can be instituted for this at-risk group.

Is obesity related with periprosthetic fractures around the knee?

Periprosthetic fracture (PPF) is a devastating complication following primary total knee arthroplasty. Obesity is currently considered a risk factor for many complications in orthopaedics, but there is no evidence in literature about the relationship between obesity and PPF around the knee. The objective of this study was to determine whether obesity is associated with a higher incidence of PPF. All patients diagnosed of a PPF around the knee from January 2010 to December 2013 were enrolled. Forty-nine PPF (47 women and 2 men) were included, and a total of 97 patients (80 women and 17 men) were randomly obtained as a control group. Body mass index (BMI) was obtained in both groups and classified as <25 (normal), overweight (25-29.9), obese (30-34.9), very obese (35-39.9), or morbid obesity (≥40). Both groups, were also divided into subpopulations depending on the age as follows: <70, 70-75, 75-80 and ≥80. Statistical analysis was performed to determine any difference in BMI ≥30kg/m² distribution between groups. In the PPF group 61.22% of the patients had a BMI over 30kg/m² and likewise 62.88% of the patients in the control group. No association was found between obesity and a higher risk of PPF (p < 0.05). As a conclusion, obesity (BMI ≥30kg/m²) does not have any clinical relationship with the appearance of a periprosthetic fracture around the knee (p < 0.05).

Association of Bisphosphonate Use and Risk of Revision After THA: Outcomes From a US Total Joint Replacement Registry.

Total hip arthroplasty (THA) is often performed in patients who are older and may take bisphosphonates to treat a variety of conditions, most commonly osteoporosis. However, the clinical effects of bisphosphonate use on patients who have undergone THA are not well described. (1) Is bisphosphonate use in patients with osteoarthritis undergoing primary THA associated with a change in the risk of all-cause revision, aseptic revision, or periprosthetic fracture compared with patients not treated with bisphosphonates? (2) Does the risk of bisphosphonate use and revision and periprosthetic fracture vary by patient bone mineral density and age? A retrospective cohort study of 12,878 THA recipients for the diagnosis of osteoarthritis was conducted; 17.8% of patients were bisphosphonate users. Data sources for this study included a joint replacement registry (93% voluntary participation) and electronic health records and an osteoporosis screening database with complete capture of cases as part of the Kaiser Permanente integrated healthcare system. The endpoints for this study were revision surgery for any cause, aseptic revision, and periprosthetic fracture. The exposure of interest was bisphosphonate use; patients were considered users if prescriptions were continuously refilled for a period equal to or longer than 6 months. Bone quality (based on dual-energy x-ray absorptiometery ordered based on the National Osteoporosis Foundation's clinical guidelines taken within 5 years of the THA) and patient age (< 65 versus ≥ 65 years) were evaluated as effect modifiers. Patient, surgeon, and hospital factors were evaluated as confounders. Cox proportional hazards models were used. Hazard ratios (HRs) and 95% confidence intervals (CIs) were determined. Age- and sex-adjusted risks of all-cause (HR, 0.50; 95% CI, 0.33-0.74; p < 0.001) and aseptic revision (HR, 0.53; 95% CI, 0.34-0.81; p = 0.004) was lower in bisphosphonate users than in nonusers. The adjusted risk of periprosthetic fractures in patients on bisphosphonates was higher than in patients not on bisphosphonates (HR, 1.92; 95% CI, 1.13-3.27; p = 0.016). Lower risks of all-cause revision and aseptic revision were observed in patients with osteopenia (HR, 0.49; 95% CI, 0.29-0.84; and HR, 0.53; 95% CI, 0.29-0.99, respectively) and osteoporosis (HR, 0.22; 95% CI, 0.08-0.62; and HR, 0.33; 95% CI, 0.11-0.99, respectively). Patients considered bisphosphonate users who underwent THA had a lower risk for revision surgery. Bisphosphonate use was associated with a higher risk of periprosthetic fractures in younger patients with normal bone quantity. Evaluation of bone quality and bisphosphonate use for the diagnosis of osteoporosis is encouraged in patients with osteoarthritis who are candidates for primary THA. Further research is required to determine the optimal duration of therapy because long-term bisphosphonate use has been associated with atypical femur fractures. Level III, therapeutic study.

PT398 Detection of Viable Myocardium By Adenosine Stress Spect-Mpi

There is little known in the literature about whether preoperative patient-reported outcome measures (PROMs) would affect the risk of periprosthetic fractures (PPFs) after primary total knee arthroplasty (TKA). Our study aims to evaluate the predictive values of PROMs on PPF after primary TKA. We hypothesize that poorer PROMs are associated with a higher risk of PPF after primary TKA.We reviewed prospectively collected data in our hospital arthroplasty registry. Patients who sustained PPF after primary TKA between 2000 and 2015 were identified. Forty-two patients were identified and matched for gender, age, and body mass index to a control group of 84 patients who had primary TKA without PPF in a 2:1 ratio. Preoperative demographics, Short Form-36 (SF-36) scores, Oxford Knee score and Knee Society Score were evaluated. Variables of PROMs were entered into a multivariate logistic regression model. A variable was considered to be a significant predictor if its odds ratio was significant at P < .05.After multivariate regression analysis, SF-36 subdomains of physical functioning (PF) and vitality (VT) were identified as significant predictors for PPFs after primary TKA. A lower SF-36 PF and VT scores were associated with higher risks of sustaining a PPF after primary TKA.From our study, low preoperative SF-36 PF and VT scores are associated with a higher risk of PPFs after primary TKA. These results can allow the preoperative identification of patients at higher risk of PPF, and appropriate preoperative counseling, optimization, and close follow-up can be instituted for this at-risk group.

Peptic ulcer disease and heart disease are associated with periprosthetic fractures after total hip replacement

Background and purpose There have been no published studies assessing the possible association of medical comorbidities with periprosthetic fracture risk. We therefore assessed whether medical comorbidity is associated with risk of periprosthetic fractures after total hip replacement (THR).Material and methods We used prospectively collected data from 1989–2008 in the Mayo Clinic Total Joint Registry for 2 cohorts: primary THR and revision THR. The main variables of interest were Deyo-Charlson comorbidities at the time of surgery. Outcome of interest was p ostoperative periprosthetic fracture at postoperative day 1 onwards. MultivariableCox regression models were additionally adjusted for age, sex, body mass index, American Society of Anesthesiology (ASA) class, and operative diagnosis.Results We identified 14,065 primary THRs and 6,281 revision THRs with mean follow-up times of 6.3 and 5.6 years, respectively. There were 305 postoperative periprosthetic fractures in the primary THR cohort and 330 in the revision THR cohort. In patients who underwent primary THR, 2 comorbidities were associated with higher risk of periprosthetic fracture: peptic ulcer disease with adjusted hazard ratio of 1.5 (95% CI: 1.1–2.2) and heart disease with adjusted hazard ratio of 1.7 (CI: 1.2–2.4). In patients with revision THR, peptic ulcer disease was associated with a higher adjusted risk of periprosthetic fracture, 1.6 (CI: 1.1–2.3).Interpretation Peptic ulcer disease and heart disease in primary THR patients and peptic ulcer disease in revision THR patients were associated with higher postoperative periprosthetic fracture risk. Further studies are needed to understand whether disease severity or specific medications used for treatment, or both, are responsible for this association. This may allow identification of modifiable factors.

Association of peptic ulcer disease and pulmonary disease with risk of periprosthetic fracture after primary total knee arthroplasty

To assess the association of specific comorbidities with periprosthetic fractures after primary total knee replacement (TKR). We used the prospectively collected data in the Mayo Clinic total joint registry from 1989-2008 on all patients who had undergone primary TKR. The outcome of interest was postoperative periprosthetic fractures during followup. The main predictors of interest were comorbidities grouped from the validated Deyo-Charlson index. Multivariable-adjusted Cox regression analyses were adjusted for sex, age, body mass index (BMI), American Society of Anesthesiology (ASA) class, operative diagnosis, and implant fixation. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated. We included 17,633 primary TKRs with a mean followup of 6.3 years. The mean age was 68 years, 55% were women, and the mean BMI was 31 kg/m(2) . There were 188 postoperative periprosthetic fractures on postoperative day 1 or later; 162 fractures (86%) occurred on postoperative day 90 or later. In multivariable analyses that simultaneously adjusted for all comorbidities and other variables (age, sex, BMI, ASA, operative diagnosis, and cement status), the following 2 conditions were significantly associated with an increased hazard of postoperative periprosthetic fractures: peptic ulcer disease (HR 1.87, 95% CI 1.28-2.75; P = 0.0014) and chronic obstructive pulmonary disease (HR 1.62, 95% CI 1.10-2.40; P = 0.02). Peptic ulcer disease and chronic obstructive pulmonary disease are associated with a higher risk of periprosthetic fractures after primary TKR. This may be related to the disease or its treatments, which need further study. Identification of specific risk factors may allow for implementation of intervention strategies to reduce this risk.

Risk factors for Periprosthetic Fractures of the Hip: A Survivorship Analysis

Periprosthetic fracture is an uncommon but typically complex complication of cemented THA usually treated operatively. It is a source of reduced function, subsequent morbidity, and increased mortality. Previous studies may have underestimated the incidence of fracture through loss to followup or failure to use survivorship methodologies. The primary aim of this study was to use survivorship methodology to investigate the incidence of, and risk factors for fracture following primary arthroplasty. We examined a cohort of 6458 primary cemented femoral prostheses implanted during a 17-year period. One hundred twenty-four patients sustained fractures at the tip or below the femoral prosthesis. The incidence of fracture was 0.8% at 5 years and 3.5% at 10 years after primary implant. Patients older than 70 years had a 2.9 times greater risk of sustaining a subsequent fracture. There was no association between fracture and gender or implant type. These rates are higher than those reported for cemented arthroplasties. Older patients should be counseled regarding their higher risk of periprosthetic fracture, and additional research is required to elucidate the biologic mechanisms involved. Level II, retrospective prognostic study.

Young age and wedge stem design are risk factors for periprosthetic fracture after arthroplasty due to hip fracture

Background It has been suggested that a hip fracture as a primary diagnosis for arthroplasty is a risk factor for periprosthetic fracture.Patients and methods We compared 16 patients with late periprosthetic fracture of the femur to 48 controls. The primary diagnosis for all patients was hip fracture. The date of operation for hip fracture was used to select the control group of patients, all of whom were operated at the same time and in the same hospital district. No other selection criteria were used. Complications at the time of index operation, type of prosthesis, age, sex, BMI, patient's diseases, medication, and surgeon's experience were compared using conditional logistic regression.Results We found that low age at the time of the hip fracture operation increased the risk of periprosthetic fracture (OR = 4.9, CI = 1.2-20). The polished wedge type of prosthesis was associated with a higher risk of periprosthetic fracture than were other designs (OR = 11, CI = 1.2-97).Interpretation These findings of risk factors for peri-prosthetic fracture are new and should be confirmed by further studies using larger numbers of patients.

Factors predisposing to periprosthetic fracture after hip arthroplasty: a case (n = 31)-control study.

We compared retrospectively 31 patients with a periprosthetic fracture to 31 patients in a control group. The Finnish Arthroplasty Register was used to count all periprosthetic fractures treated by revision arthroplasty in Finland and in Tampere University Hospital district during the years 1990-1999. We used the date of the previous operation to find the control group patients operated on at the same time in the same hospital district. No other selection or matching criteria were used. The type of prosthesis, complications, age, BMI, cementation and primary diagnosis were compared. We found that patients who had a fracture as the primary diagnosis ran a 4.4 (95%CI = 1.4-14) times higher risk of periprosthetic fracture than those operated on for other reasons.