Intraoperative Periprosthetic Fractures Research Articles

Long-term outcomes of the mayo conservative hip system in patients aged 30years or less with osteonecrosis of the femoral head: mean follow-up of more than 10years.

Historically, total hip arthroplasty (THA) in very young patients has been associated with lower survivorship. However, the long-term outcomes of THA using short stems for osteonecrosis of the femoral head (ONFH) in very young patients remain unclear. Therefore, this study aimed to investigate the long-term outcomes of the Mayo conservative hip system, a short metaphyseal stabilised stem, in patients with ONFH aged ≦30years. We retrospectively reviewed 104 joints in 76 patients with ONFH who underwent THA using the Mayo conservative hip system with a minimum follow-up of 8years. The mean follow-up period was 12.5 (range, 8-19) years. Patients were categorised into two age groups (≦30years, n = 21 and > 30years, n = 83). Radiographic evaluation was used to assess stem sinking, stress shielding, and spot welds. The clinical evaluations were performed using the Japanese Orthopedic Association (JOA) hip score. Postoperative major complication and revision surgery rates were also assessed. The patient characteristics were similar between the two groups, except for the age. Revision surgeries were performed in five cases, with similar implant survival rates between the groups. Dislocations occurred in the older age group alone (four joints). One case of intra-operative periprosthetic femoral fracture was found in the younger age group. Stem sinking of > 3mm occurred in one and seven joints in the younger and older age groups, respectively. Spot welds were observed in most joints (93.2%) in modified Gruen zones 2 and 6 without significant differences between the groups. Stress shielding showed no significant differences in the frequency of occurrence or location between the two groups. Furthermore,the JOA score showed no significant difference between the two groups. The use of short stems in patients aged ≤ 30years with ONFH showed favourable long-term outcomes.

DOES AN INTRAOPERATIVE FEMORAL FRACTURE IMPACT ONE-YEAR PATIENT-REPORTED OUTCOME MEASURES WHEN USING A CEMENTLESS CORAIL STEM?

The significance of periprosthetic fractures about a total hip arthroplasty (THA) is becoming increasingly important. Recent studies have demonstrated post-operative periprosthetic fracture rates are higher amongst cemented polished taper slip (PTS) stem designs compared to collared cementless (CC) designs.However, in the National Joint Registry, the rate of intra-operative periprosthetic femoral fractures (IOPFF) with cementless implant systems remains higher (0.87% vs 0.42%. p <0.001) potentially leading to more post-operative complications.This study identifies the incidence of IOPFF, the fracture subtype and compares functional outcomes and revision rates of CC femoral implants with an IOPFF to CC stems and PTS stems without a fracture.5376 consecutive CC stem THA, carried out through a posterior approach were reviewed for IOPFF. Each fracture was subdivided into calcar fracture, greater trochanter (GT) fracture or shaft fracture.1:1:1 matched analysis was carried out to compare Oxford scores at one year. Matching criteria included; sex (exact), age (± 1 year), American Society of Anaesthesiologists (ASA) grade (exact), and date of surgery (± 6 months).Electronic records were used to review revision rates.Following review of the CC stems, 44 (0.8%) were identified as having an IOPFF. Of these 30 (0.6%) were calcar fractures, 11 (0.2%) GT fractures and 3 (0.06%) were shaft fractures. There were no shaft penetrations.Overall, no significant difference in Oxford scores at one year were observed when comparing the CC IOPFF, CC non-IOPFF and PTS groups.There were no CC stems revised for any reason with either a calcar fracture or trochanteric fracture within the period of 8 years follow-up.IOPFF do occur more frequently in cementless systems than cemented. The majority are calcar and GT fractures. These fractures, when identified and managed intra-operatively, do not have worse functional outcomes or revision rates compared to matched non-IOPFF cases.

Outcomes of conversion total hip arthroplasty for failed fixation of intertrochanteric fractures with monoblock distal-loading reconstruction stem.

The aim of our study was to analyze the clinical and radiological outcomes of conversion total hip arthroplasty (THA) for failed fixation of proximal femur fractures with monoblock grit-blasted titanium reconstruction stem (Wagner self-locking stem, Zimmer). Thirty-nine patients were included in this retrospective analysis undergoing conversion THA for failed cephalomedullary nail or dynamic hip screw fixation for intertrochanteric fractures from January 2017 to January 2022. The clinical evaluation was done using Harris hip score. The radiological outcomes measured were subsidence, level of osteointegration, stem-canal fill ratio and heterotopic bone formation. The complications were noted postoperatively and during the follow-up. The mean follow-up at the end of the study was 27.8months (range, 14-72months). There was a significant improvement in the Harris hip score over serial follow-ups (p < 0.001), but after 2years, there was no statistically significant difference (p = 0.46). According to Engh's criteria, stable ingrowth was noted in 35 stems, fibrous stable ingrowth was noted in 4 stems and no patients had progressive subsidence and unstable stem. The mean stem-canal fill percentages were 91.8 ± 5.4% at the mid-stem and 80.3 ± 11.5% at the stem tip. Heterotopic ossification Brooker grade 2 was noted in 8 patients, and no patients had grade 3 or 4 heterotopic ossification. There were 7 (17.9%) intraoperative periprosthetic fractures, and greater trochanteric avulsion was noted in 2 patients in the follow-up. Conversion THA using monoblock tapered distal loading stems bypasses the calcar deficiency and gives stable fixation in failed fixation of intertrochanteric fractures. It gives good radiological outcome and significant improvement in the clinical outcomes compared to the preoperative disability. However, caution should be noted for risk of intraoperative periprosthetic fractures in this subgroup of patients.

Mid-term results of total hip arthroplasty with anatomical ultra-short cementless stem in patients with developmental dysplasia of the hip Crowe type II

The aim of this study was to present the mid-term results of ultra-short cementless stem total hip arthroplasty (THA) in patients with Crowe type II developmental dysplasia of the hip. The study consists of 68 patients (75 THAs) with a Proxima stem implanted between 2006 and 2015. The clinical results include Harris Hip Scores. Radiological follow-up reports on stem migration, bony trabecular development and radiolucent lines. Kaplan–Meier survival analysis was performed. The mean age of patients was 48.4 years, with a mean follow-up 114 months. The average Harris Hip Score improved significantly from 45.1 preoperatively to 97.6 at the final evaluation (p < 0.001). Stem migration was observed in five hips (in all of them up to the 6th postoperative month, without any further progression of migration or radiological loosening). Bony trabecular development was detected in modified Gruen zones (1, 2, 4, 6, 7 for Proxima stem): in zone 1 (0%), 2 (49.3.0%), 4 (38.7%), 6 (82.7%), 7 (0%). Radiolucent lines were observed around one cup (DeLee and Charnley zone I) and three stems (none was loose, all three with fibrous stable fixation). Complications were found in three hips (4.0%): intraoperative periprosthetic femoral fracture (threated with cerclage wire) in two hips and squeezing hip in one patient (with perioperative ceramic inlay breakage and exchange). No hip was revised. The implant survival was 100.0% both clinically and radiologically. Observations in the mean follow-up of 114 months show that the results (clinical and radiological) of the Proxima stem in patients with Crowe type II DDH are promising.

Small design modifications can improve the primary stability of a fully coated tapered wedge hip stem.

Increasing the stem size during surgery is associated with a higher incidence of intraoperative periprosthetic fractures in cementless total hip arthroplasty with fully coated tapered wedge stems, especially in femurs of Dorr type A. If in contrast a stem is implanted and sufficient primary stability is not achieved, such preventing successful osseointegration due to increased micromotions, it may also fail, especially if the stem is undersized. Stem loosening or periprosthetic fractures due to stem subsidence can be the consequence. The adaptation of an established stem design to femurs of Dorr type A by design modifications, which increase the stem width proximally combined with a smaller stem tip and an overall shorter stem, might reduce the risk of distal locking of a proximally inadequately fixed stem and provide increased stability. The aim of this study was to investigate whether such a modified stem design provides improved primary stability without increasing the periprosthetic fracture risk compared to the established stem design. The established (Corail, DePuy Synthes, Warsaw, IN, US) and modified stem designs (Emphasys, DePuy Synthes, Warsaw, IN, US) were implanted in cadaveric femur pairs (n = 6 pairs) using the respective instruments. Broaching and implantation forces were recorded and the contact areas between the prepared cavity and the stem determined. Implanted stems were subjected to two different cyclic loading conditions according to ISO 7206-4 using a material testing machine (1 Hz, 600 cycles @ 80 to 800 N, 600 cycles @ 80 to 1600 N). Translational and rotational relative motions between stem and femur were recorded using digital image correlation. Broaching and implantation forces for the modified stem were up to 40% higher (p = 0.024), achieving a 23% larger contact area between stem and bone (R2 = 0.694, p = 0.039) resulting in a four times lower subsidence during loading (p = 0.028). The slight design modifications showed the desired effect in this in-vitro study resulting in a higher primary stability suggesting a reduced risk of loosening. The higher forces required during the preparation of the cavity with the new broaches and during implantation of the stem could bare an increased risk for intraoperative periprosthetic fractures, which did not occur in this study.

Age as a Risk Factor for Intraoperative Periprosthetic Femoral Fractures in Cementless Hip Hemiarthroplasty for Femoral Neck Fractures: A Retrospective Analysis.

Understanding the risk factors and outcomes of intraoperative periprosthetic femoral fractures (IPFF) during hip arthroplasty is crucial for appropriate perioperative management. Previous studies have identified risk factors for IPFF in total hip arthroplasty patients, but data for hip hemiarthroplasty (HA) is lacking. The aim of this study was to determine the age associated with increased rates of IPFF in patients undergoing HA. We retrospectively reviewed patients aged 65 years and above who underwent a cementless HA for a displaced femoral neck fracture and had a minimum of 1-year follow-up. Patients were stratified into five age groups (65-79, 80-84, 85-89, 90-94, and ≥ 95 years) and further divided into two subgroups (under 95 years and 95 years or older). The presence, location, and treatment of IPFF, as well as the effect of IPFF on the postoperative weight-bearing status, were compared between groups. A multivariate logistic regression was also performed. A total of 1,669 met the inclusion criteria and were included in the study. The rates of IPFF were significantly higher for patients 95 years or older (p = 0.030). However, fracture location (greater trochanter fractures, p = 0.839; calcar fractures, p = 0.394; and femoral shaft fractures p = 0.110), intraoperative treatment (p = 0.424), and postoperative weight-bearing status (p = 0.229) were similar between the groups. While mortality and nonorthopedic-related readmissions were significantly higher for patients 95 years or older, orthopedic-related readmissions (p = 0.148) and revisions at the latest follow-up (p = 0.253) were comparable between groups. In a regression analysis, age over 95 years (odds ratio, 2.049; p = 0.049) and body mass index (odds ratio, 0.935; p = 0.016) were independently associated with IPFF. The findings of this study suggest that age over 95 years is a significant, independent risk factor for IPFF in patients undergoing cementless HA. Although we were unable to show an impact on perioperative outcomes and orthopedic complications, when operating on patients 95 years or older, surgeons should be aware of the increased risk of IPFF and consider the use of stem designs and fixation types associated with decreased IPFF rates.

Comparison of clinical results of flat-tapered and rectangular stems in partial hip replacement based on proximal femur fracture

Aim: Hemiartroplasty is also commonly used in proximal femur fractures to provide early mobilization and weight bearing to the patient. Cemented and cementless femoral stems are commonly used in this procedure. Cementless prostheses have many advantages and disadvantages, and their relevance to stem design is controversial. The purpose of this study was to compare flat-tapered and rectangular femoral stems in hemiartroplasty.&#x0D; &#x0D; Methods: The study population consisted of archive orthopedics and traumatology clinic of a third-level hospital. This was a retrospective study. A total of 176 patients underwent cementless hemiarthroplasty for proximal femoral fractures. Within these protocols, 64 patients underwent hemiarthroplasty using a flat-tapered stem (Group 1) and 58 patients underwent hemiarthroplasty using a rectangular stem (Group 2).&#x0D; &#x0D; Results: No significant differences were observed in terms of functional scores and Visual Analogue Scale values among the patients. The study groups were analyzed in terms of developing complications. Similar results were found in both groups when compared in terms of periprosthetic femur fractures .&#x0D; Conclusion: Various risk factors have been described for intraoperative periprosthetic femur fractures, including advanced age, poor bone quality, and surgeon ’s operative volüme. Various studies have reported a higher periprosthetic femur fractures rate in hip arthroplasty performed using rectangular stems. It has been reported that geometrical features may be the main reason for this. In our study, we could not find any significant difference between flat-tapered and rectangular stems in terms of clinical outcomes and periprosthetic femur fracture in cases of cementless hemiarthroplasty. As a result, rectangular stems should be safely preferred in hemiarthroplasty.

Subtrochanteric Shortening Osteotomy Provides Superior Function to Trochanter Slide Osteotomy in THA for Patients With Unilateral Crowe Type IV Dysplasia at a Minimum of 3 Years.

Performing THA in patients with high-riding developmental dysplasia of the hip (DDH) is associated with serious complications and technical challenges. Various methods of shortening osteotomy are available to facilitate femoral head reduction during THA in patients with high-riding hips; subtrochanteric shortening osteotomy and trochanteric slide osteotomy plus proximal shortening are the most common techniques. However, which approach is superior remains a topic of controversy. (1) Is there any difference in clinical outcomes (defined as the Harris Hip Score [HHS] and residual limb length discrepancy) at a minimum of 3 years between subtrochanteric shortening osteotomy and trochanteric slide osteotomy in patients with Crowe Type IV DDH who underwent THA? (2) Is there any difference in the risk or type of complications between the two approaches? We performed a retrospective, comparative study of two groups (subtrochanteric shortening osteotomy versus trochanteric slide osteotomy) matched for sex and preoperative HHS at a minimum of 3 years of follow-up. Between 2010 and 2018, we performed 67 THAs in patients with unilateral Crowe Type IV DDH. During that time, we generally used a trochanteric slide osteotomy for THA in all patients with Crowe Type IV hips and performed subtrochanteric shortening osteotomy when a conical stem was not available. A total of 42% (28) had THA with subtrochanteric shortening osteotomy, and 58% (39) had THA with trochanteric slide osteotomy. Of those, 89% (25) and 74% (29), respectively, were accounted for with complete datasets for possible matching at a minimum of 3 years of follow-up. Patients were matched for gender and preoperative HSS (within 10 points), leaving 22 patients in each group (79% of the subtrochanteric shortening osteotomy group and 56% of the trochanteric slide osteotomy group) for evaluation and analysis. Age (42 versus 46 years), gender (female: 73% versus 73%), preoperative HSS (40 versus 40), and preoperative leg length discrepancy (5.9 versus 5.3 cm) were comparable between the two groups (p > 0.05). The trochanteric slide osteotomy group exclusively received Cone Wagner (Zimmer) implants (100%), while Corail (DePuy Synthes) implants (77%) were the most commonly used in the subtrochanteric shortening osteotomy group. HHS at a minimum of 3 years as well as the presence or absence of a limp and Trendelenburg sign, functional leg length discrepancy, nonunion, nerve palsy, and other surgical complications were recorded and compared between the groups based on data drawn from a longitudinally maintained institutional database. At a mean follow-up of 73 months, improvement in HHS was greater in the subtrochanteric shortening osteotomy group than in the trochanteric slide osteotomy group (48 ± 4 points versus 36 ± 11 points, mean difference 12 points [95% CI 7 to 17 points]; p < 0.001). Although the preoperative leg length discrepancy was similar between the groups, there was a greater postoperative improvement in the subtrochanteric shortening osteotomy group (44 ± 8 mm and 38 ± 8 mm in the subtrochanteric shortening osteotomy and trochanteric slide osteotomy groups, respectively; p = 0.02). The risk of nonunion was higher with a trochanteric slide osteotomy than with a subtrochanteric shortening osteotomy (23% [5 of 22] versus 0% [0 of 22]; p = 0.048). Other complications, including intraoperative periprosthetic fractures, nerve palsy, heterotopic ossification, revision surgery, and dislocation, did not differ between the groups. In patients with Crowe Type IV hips undergoing THA, surgeons might consider subtrochanteric shortening osteotomy rather than trochanteric slide osteotomy to minimize the risk of nonunion and achieve superior hip function. Better correction of leg length discrepancy may also be possible with subtrochanteric shortening osteotomy. The long-term survivorship of hips after these two techniques, as well as the influence of the specific anatomy of the proximal femur on the choice of technique, remain to be explored in future studies. Level III, therapeutic study.

Risk Factors for Peripheral Nerve Injury Following Revision Total Knee Arthroplasty in 132,960 Patients

BackgroundPeripheral nerve injury (PNI) following revision total knee arthroplasty (rTKA) is a potentially devastating injury for patients. This study assessed the frequency of and risk factors for postoperative PNI following rTKA. MethodsPatients who underwent rTKA from 2003 to 2015 were identified using the National Inpatient Sample. Demographics, medical histories, surgical details, and complications were compared between patients who sustained a PNI and those who did not to identify risk factors for the development of PNI after rTKA. ResultsOverall, 132,960 patients who underwent rTKA were identified, and 737 (0.56%) sustained a postoperative PNI. After adjusting for confounders, patients with a history of a spine condition (adjusted odds ratio [aOR]: 1.7, 95%-confidence interval 1.2 to 2.4, P = .003) and postoperative anemia (aOR: 1.3, 95%-CI: 1.1 to 1.5, P = .004) had higher risk of PNI following rTKA. Intraoperative periprosthetic fracture (aOR: 1.3, 0.78 to 2.2, P = .308), rheumatoid arthritis (aOR: 1.0, 95%-CI: 0.68 to 1.6, P = .865), and history of knee dislocation (aOR: 1.1, 95%-CI: 0.85 to 1.5, P = .412), were not significantly associated with higher risk for PNI. ConclusionsThis study found a 0.56% incidence of PNI following rTKA, and patients who had preexisting spine conditions or postoperative anemia were at an increased risk for this complication. Orthopedic surgeons may use the results of this study to appropriately counsel patients on the potential for a PNI following rTKA.

Management of complications of mega-implants following treatment of primary and periprosthetic fractures of the lower extremities

In recent years, indications for implanting mega-implants were established in managing major bone defects linked to revision arthroplasty due to loosening, periprosthetic fractures, re-implantation following periprosthetic joint infection, non-union following fractures as well as complex intraarticular primary fractures. This study was conducted to discuss and analyze the strategy of diagnosis and management of complications following the use of mega-implants in treating primary and periprosthetic fractures of the lower extremities. This is a monocentric retrospective study. Patients aged ≥ 18 years who underwent implantation of a megaendoprosthesis due to periprosthetic or primary fractures of the lower extremity between January 2010 and February 2023 were identified from the authors’ hospital information system. We identified 96 patients with equal numbers of fractures (71 periprosthetic fractures and 25 primary fractures). 90 cases out of 96 were investigated in this study. The drop-out rate was 6.25% (six cases). The average follow-up period was 22 months (1 to 8 years) with a minimum follow-up of 1 year. The diagnosis of complications was provided on the basis of subjective symptoms, clinical signs, radiological findings and laboratory investigations such as C-reactive protein, leucocyte count and the microbiological findings. The indications for implantations of modular mega-implants of the lower extremities were periprosthetic fractures (65 cases/72.22%) and primary fractures (25 cases/27.78%). Pathological fractures due to malignancy were encountered in 23 cases (25.56%), in one case due to primary tumor (1.11%) and 22 cases due to metastatic lesions (24.44%). Two cases (2.22%) presented with primary intraarticular fractures with severe osteoporosis and primary arthrosis. In all cases with malignancy staging was performed. Regarding localization, proximal femur replacement was encountered in 60 cases (66.67%), followed by distal femur replacement (28 cases/31.11%) and total femur replacement (2 cases/2.22%). The overall complication rate was 23.33% (21 complications in 21 patients). The most common complication was dislocation which was encountered in nine cases (10%), all following proximal femoral replacement (9 cases out of 60, making 15% of cases with proximal femoral replacement). The second most common complication was infection (six cases, 6.67%), followed by four aseptic loosenings (4.44%), further intraoperative periprosthetic fracture in one case (1.11%) and a broken implant in one case (1.11%). We noticed no cases with wear and tear of the polyethylene components and no cases of disconnections of the modular components. Mega-endoprostheses enable versatile management options in the treatment of primary and periprosthetic fractures of the lower extremities. The rate of complications such as loosening, implant failure, dislocation and infection are within an acceptable range in this preliminary analysis. However, implantation of mega-endoprostheses must be strictly indicated due the limited salvage options following surgery.

Incidence and outcomes of intraoperative periprosthetic acetabular fractures during cementless total hip arthroplasty: a prospective three-dimensional computer tomography-based study.

Unlike periprosthetic femoral fractures, periprosthetic acetabular fractures during total hip arthroplasty (THA) have not been evaluated in detail. We prospectively evaluated the incidence, patterns, risk factors, and clinical outcomes of intraoperative periprosthetic acetabular fractures using pre- and postoperative computer tomography (CT). In this prospective single-centre study, we evaluated 234 consecutive patients (250 hips) who underwent THA and three-dimensional CT before and after the surgery. We assessed the incidence, pattern of fractures, outcomes for each fracture pattern, reoperation and revision rates, Harris hip score, and visual analog scale (VAS) for pain. Multivariate regression models were used to identify risk factors for periprosthetic acetabular fractures. In total, 43 periprosthetic acetabular fractures (17.2%) were identified via CT. Fractures occurred most frequently at the superolateral wall. Early cup migration occurred in three hips. None of the patients underwent revision surgery for acetabular loosening. Regression modeling showed that rheumatoid arthritis was a significant predictor of periprosthetic acetabular fractures. Periprosthetic acetabular fractures are not infrequent during cementless THA and are more common in patients with rheumatoid arthritis.

Intraoperative Periprostehtic Femur Fracture - When is the Cerclage Enough?

Intraoperative periprosthetic femoral fractures are among the most serious complications in both primary and revision arthroplasty. They are often not detected, despite intraoperative radiological control. Since an unnoticed intraoperative fracture often requires revision surgery, which has been associated with increased mortality rates, intraoperative diagnosis and corresponding direct and sufficient treatment are crucial. There are patient-, surgery-, and implant-specific risk factors that increase the possibilities of intraoperative fractures. The most common risk factors on the patient side are age, gender, and various pre-existing conditions, such as osteoporosis or rheumatic diseases. A minimally invasive approach and a cementless press-fit fixation are the most significant surgery- and implant-specific risk factors. The Vancouver classification or the modified Mallory classification are available for the classification of intraoperative periprosthetic femoral fractures. Based on these classifications, treatment recommendations can be derived. Different strategies are available for fracture management. Generally, if the stem is stable, osteosynthesis can be performed with preservation of the implant. This procedure can be applied to the majority of cases with non-displaced fractures by using cerclages as fixation. An unstable implant may require replacement of the stem. In higher grade fractures, stabilisation by using plate osteosynthesis may be necessary. The aim is to achieve the most anatomical reposition possible for the best possible bony consolidation. The ultimate goal is high implant stability and restoration of the biomechanics.

Cemented versus uncemented stems for revision total hip replacement: A systematic review and meta-analysis.

The popularity of uncemented stems in revision total hip arthroplasty (THA) has increased in the last decade. To assess the outcomes of both cemented and uncemented stems after mid-term follow up. This study was performed following both the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement and the Cochrane Handbook for systematic reviews and meta-analysis guidelines. Articles were chosen irrespective of country of origin or language utilized for the article full texts. This paper included studies that reviewed revision THA for both cemented or uncemented long stems. Three eligible studies were included in the meta-analysis. Analysis was conducted by using Review Manager version 5.3. We computed the risk ratio as a measure of the treatment effect, taking into account heterogeneity. We used random-effect models. There were no significant differences found for intraoperative periprosthetic fractures [risk ratio (RR) = 1.25; 95% confidence interval (CI): 0.29-5.32; P = 0.76], aseptic loosening (RR = 2.15, 95%CI: 0.81-5.70; P = 0.13), dislocation rate (RR = 0.50; 95%CI: 0.10-2.47; P = 0.39), or infection rate (RR = 0.99, 95%CI: 0.82-1.19; P = 0.89), between the uncemented and the cemented long stems for revision THA after mid-term follow-up. This study has evaluated the mid-term outcomes of both cemented and uncemented stems at first-time revision THA. In summary, there were no significant differences in the dislocation rate, aseptic loosening, intraoperative periprosthetic fracture and infection rate between the two cohorts.

Diagnosis and Management of Intraoperative Periprosthetic Fractures in Primary Total Knee Arthroplasty.

Intraoperative periprosthetic fracture is an uncommon but notable complication that can occur during primary total knee arthroplasty. These fractures may occur at various stages during the procedure, including surgical exposure, implant preparation, implant trialing, and final implantation. Management of femoral and tibial fractures necessitates intraoperative recognition, including attentiveness of preoperative patient and surgical risk factors. This comprehensive review article focuses on the patient and surgical risk factors, diagnosis, management, and outcomes related to intraoperative fractures during primary total knee arthroplasty.

Higher Annual Total Hip Arthroplasty Volume Decreases the Risk of Intraoperative Periprosthetic Femur Fractures

BackgroundPeriprosthetic femur fracture (PFF) is a complication of total hip arthroplasty (THA). These occur intraoperatively or postoperatively, and documented risk factors of PFFs include women, age greater than 65 years, cementless stems, and inflammatory arthropathies. The aim of this retrospective cohort study was to assess the relationship of years of surgical experience and surgeon annual THA volume on intraoperative and postoperative PFFs. MethodsData were collected from a database query, and PFFs were identified as either intraoperative or postoperative. Intraoperative and postoperative PFFs were both compared to a control group of non-PFF patients. Years of surgical experience at the time of surgery and annual THA volume for the primary surgeon were calculated for all cases. Logistic regression analyses were used to calculate odds ratios for each of the surgeon variables when adjusted for patient demographics. ResultsThirty-seven intraoperative and 108 postoperative PFFs were identified and compared to 7,629 controls. From regression analyses, high-volume surgeons (≥50 THA/year) had lower odds of intraoperative PFF (adjusted odds ratio (aOR) = 0.40, P = .020) but not postoperative PFF (aOR = 1.02, P = .921). Surgeon experience (≥15 years since board certification at the time of surgery), was not significantly related to either PFF outcomes. For patient factors, age ≥65 years (aOR = 2.30, P < .001) and women (aOR = 2.69, P < .001) were both significant predictors of postoperative PFFs only. ConclusionSurgeons who performed 50 or more THAs per year had significantly fewer intraoperative PFFs than surgeons who did less than 50 THAs per year. Surgeon experience was not significantly related to PFFs.

Association of osteoporosis and high serum homocysteine levels with intraoperative periprosthetic fracture during total hip arthroplasty: a propensity-score matching analysis.

Intraoperative periprosthetic fracture, one of the most frequent complications of total hip arthroplasty, is a very important factor that affects rehabilitation, hospitalization time, and cost of treatment. Osteoporosis is common in total hip arthroplasty patients and likely contributes to the increasing incidence of periprosthetic fracture. Despite this awareness, preoperative and postoperative osteoporosis evaluations remain insufficient. The purpose of this study was to evaluate the relationships between the occurrence of intraoperative periprosthetic fractures and both bone mineral density (BMD) and osteoporosis-related biomarkers. This single-center retrospective study included a total of consecutive 487 hip joints of patients with a mean age of 65.5 ± 11.8years who underwent total hip arthroplasty between July 2017 and December 2020. Patients with low BMD defined as T-score < -1.0 versus those with normal BMD were matched by a 1:1 propensity score to balance for patient baseline characteristics, and outcome was analyzed by a modified Poisson regression model. Our primary outcome was the incidence of intraoperative periprosthetic fracture during surgery. We also investigated the effect modification of osteoporosis-related biomarkers, including tartrate-resistant acid phosphatase 5b (TRACP-5b), total procollagen type 1 amino-terminal propeptide (total P1-NP), intact parathyroid hormone (intact PTH), and homocysteine, on osteoporosis and outcomes. After matching, 250 patients were analyzed. The risk of fracture was significantly higher in patients with low BMD than in normal BMD patients (Incidence rate ratio 5.00 [95% CI 1.11-22.43], p = 0.036). We also observed significant effect of high serum homocysteine on the occurrence of intraoperative fractures (Incidence rate ratio 8.38 × 106 [95% C; 3.44 × 106-2.01 × 107], p < 0.01). Preoperative osteoporosis and high serum homocysteine levels were risk factors for intraoperative periprosthetic fractures. III, A single-center retrospective study.

Contemporary outcomes of primary total hip arthroplasty in patients with inflammatory arthritis.

Contemporary outcomes of primary total hip arthroplasties (THAs) with highly cross-linked polyethylene (HXLPE) liners in patients with inflammatory arthritis have not been well studied. This study examined the implant survivorship, complications, radiological results, and clinical outcomes of THA in patients with inflammatory arthritis. We identified 418 hips (350 patients) with a primary diagnosis of inflammatory arthritis who underwent primary THA with HXLPE liners from January 2000 to December 2017. Of these hips, 68% had rheumatoid arthritis (n = 286), 13% ankylosing spondylitis (n = 53), 7% juvenile rheumatoid arthritis (n = 29), 6% psoriatic arthritis (n = 24), 5% systemic lupus erythematosus (n = 23), and 1% scleroderma (n = 3). Mean age was 58 years (SD 14.8), 66.3% were female (n = 277), and mean BMI was 29 kg/m2 (SD 7). Uncemented femoral components were used in 77% of cases (n = 320). Uncemented acetabular components were used in all patients. Competing risk analysis was used accounting for death. Mean follow-up was 4.5 years (2 to 18). The ten-year cumulative incidence of any revision was 3%, and was highest in psoriatic arthritis patients (16%). The most common indications for the 15 revisions were dislocations (n = 8) and periprosthetic joint infections (PJI; n = 4, all on disease-modifying antirheumatic drugs (DMARDs)). The ten-year cumulative incidence of reoperation was 6.1%, with the most common indications being wound infections (six cases, four on DMARDs) and postoperative periprosthetic femur fractures (two cases, both uncemented femoral components). The ten-year cumulative incidence of complications not requiring reoperation was 13.1%, with the most common being intraoperative periprosthetic femur fracture (15 cases, 14 uncemented femoral components; p = 0.13). Radiological evidence of early femoral component subsidence was observed in six cases (all uncemented). Only one femoral component ultimately developed aseptic loosening. Harris Hip Scores substantially improved (p < 0.001). Contemporary primary THAs with HXLPE in patients with inflammatory arthritis had excellent survivorship and good functional outcomes regardless of fixation method. Dislocation, PJI, and periprosthetic fracture were the most common complications in this cohort with inflammatory arthritis.

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

BackgroundRegistry data have demonstrated lower rates of revision and periprosthetic fracture in select cohorts with cemented femoral fixation at primary total hip arthroplasty. Whether this is true of all component designs is not known. We hypothesized that selected use of ream-and-broach triple-tapered uncemented stem designs may provide comparable results to cemented stems. MethodsFrom 2000 to 2018, 5,809 primary total hip arthroplasties were performed with either a cemented (1,304) or ream-and-broach triple-tapered uncemented stem (4,505). Implant choice was at surgeon discretion. The cemented group was older, more often women, and had slightly lower body mass index. A subgroup analysis was performed on patients ≥75 years of age. Statistical weighting accounted for baseline cohort differences. ResultsAt 10 years, there was a trend toward higher all-cause revision (hazards ratio (HR) 1.6, P = .053) and higher all-cause reoperation (HR 1.6, P = .02) in the cemented fixation cohort. The cemented fixation group had fewer intraoperative periprosthetic fractures (HR 0.21, P < .001) but no difference in postoperative fractures (HR 0.99, P = .96). The same was true in patients ≥75 years. In the ≥75-years subgroup, there was no difference in revision or reoperation at 10 years. ConclusionCompared to cemented stems, the use of ream-and-broach triple-tapered uncemented stems in select patients, including those ≥75 years, was associated with more intraoperative fractures but no difference in 10-year implant survivorship. These findings are different than some registry data and suggest that specific uncemented components, implanted in selected patients by experienced surgeons, can perform as well as cemented implants in a broad patient population.

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

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

Functional outcomes of periprosthetic and non-periprosthetic distal femur fractures: a comparative study

Aim: The purpose of this study was to compare the outcomes of locked plating in closed distal femur periprosthetic, and non-periprosthetic fractures. We hypothesized that the outcomes would be superior in the non-periprosthetic distal femur fracture group.&#x0D; Material and Method: Patients who underwent surgery for distal femur fractures between January 2019 and January 2022 were retrospectively reviewed. Patients aged under 18 years, who had multiple fractures, pathological fractures, follow-up less than 6 months, previous history of revision knee arthroplasty, interprosthetic fractures between hip and knee arthroplasties, fixation performed other than distal locking femoral plate and intra-operative periprosthetic fractures were excluded. Patients’ age, gender, laterality, length of hospital stay, and follow-up duration were obtained from hospital registry notes. Fractures were classified using the AO classification system. At the last follow-up, visual analogue scale (VAS), Tegner activity score, Lysholm knee score, and short form 36 (SF-36) scores were noted.&#x0D; Results: A total of 30 patients met the inclusion criteria and were included in the study. There were 14 patients in the non-periprosthetic fracture group and 16 patients in the periprosthetic fracture group. The periprosthetic group had significantly lower mean VAS score (p=0.047), Tegner activity score (p=0.015), and Lysholm knee score (p=0.034) than the non-periprosthetic group. The periprosthetic fracture group had significantly inferior quality of life scores compared to non-periprosthetic groups based on SF-36 sub-parameters.&#x0D; Conclusion: Periprosthetic distal femoral fractures have inferior clinical outcomes and quality of life than non-periprosthetic fractures despite having similar fracture healing rate. Orthopaedic surgeons should be aware of the frailty of the patients caused by prior total knee arthroplasty surgery.