Intraoperative Periprosthetic Fractures Research Articles

High Incidence of Intraoperative Fractures With a Specific Cemented Stem Following Intracapsular Displaced Hip Fracture

BackgroundTo reduce costs of orthopedic implants, the government decided to standardize implants used across different specialties in a group of hospitals located in the same geographic area. The usual cemented stem used in the context of intracapsular displaced geriatric hip fractures was replaced by another stem. Abnormal intraoperative calcar and trochanteric fractures were noted. The purpose of this study is to determine the incidence of intraoperative periprosthetic fractures following an intracapsular displaced hip fracture treated with this specific cemented stem compared to the previous implant. MethodsThis is a retrospective cohort study comparing an historic cohort of hip fractures treated with the OmniFit EON (Stryker, Kalamazoo, MI) cemented stem with a new cohort of patients who received the Corail (DePuy Synthes, Warsaw, IN) cemented stem. Four orthopedic surgeons reviewed operative reports and postoperative radiographs. ResultsThe treatment group included 348 patients who received the Corail stem. The control group included 77 patients. The 2 groups had similar baseline characteristics (P > .05) except for the presence of dementia. Incidence of intraoperative calcar or greater trochanteric fracture was 15.5% for the Corail group and 2.7% for the control group (P < .05). No patient-related factors or surgeon-related factors were related to a higher number of fractures in the treatment group (P > .05). ConclusionThe Corail cemented stem presents an abnormal number of iatrogenic intraoperative fractures following displaced femoral neck fracture in our geriatric population. No external factor seems to explain this high number of fractures. Implant design should be questioned. Level of EvidenceIII.

Patient-reported outcome after stemmed versus stemless total shoulder arthroplasty for glenohumeral osteoarthritis: a patient-blinded randomized clinical trial

BackgroundStemless shoulder arthroplasty systems with uncemented metaphyseal fixation have been used for glenohumeral osteoarthritis since 2004 (Hawi, et al. BMC Musculoskelet Disord 17:376, 2016). The stemless design has several theoretical advantages compared with the stemmed shoulder arthroplasty systems: restoring patients’ anatomy; preserving humeral bone stock; and few complications in component removal if the need for a revision arthroplasty arises. The purpose of the study is to compare the short-term, patient-reported outcome of stemless and stemmed total shoulder arthroplasty (TSA).Materials and methodsA randomized clinical trial will be conducted. Eighty patients with clinical and radiological signs of primary or post-traumatic glenohumeral osteoarthritis, computed tomography (CT) scan-verified adequate glenoid bone stock, and no total rupture of rotator cuff tendons verified by a magnetic resonance imaging (MRI) scan will be randomly allocated to a stemless or stemmed TSA. The primary outcome will be the Western Ontario Osteoarthritis Shoulder (WOOS) score at 12 months. Secondary outcomes are the WOOS score at three months and the Oxford Shoulder Score (OSS) and EQ-5D at 3 and 12 months. All complications, including glenoid and humeral component loosening, instability, rotator cuff tear, intraoperative and postoperative periprosthetic fracture, nerve injury, infection, deltoid injury, and symptomatic deep venous thrombosis, will be reported.DiscussionFindings will provide patients with better information about the potential benefits and harms of stemless and stemmed TSA and will assist shoulder surgeons and patients in decision-making.Trial registrationClinicaltrials.gov, NCT03877315. Registered on 13 March 2019.

Risk Factors for Intraoperative Periprosthetic Femoral Fractures During Primary Total Hip Arthroplasty. An Analysis From the National Joint Registry for England and Wales and the Isle of Man

BackgroundThe aim of this study is to estimate risk factors for intraoperative periprosthetic femoral fractures (IOPFF) and each anatomic subtype (calcar crack, trochanteric fracture, femoral shaft fracture) during primary total hip arthroplasty. MethodsThis retrospective cohort study included 793,823 primary total hip arthroplasties between 2004 and 2016. Multivariable regression modeling was used to estimate relative risk of patient, surgical, and implant factors for any IOPFF and for all anatomic subtypes of IOPFF. Clinically important interactions were assessed using multivariable regression. ResultsPatient factors significantly increasing the risk of fracture were female gender, American Society of Anesthesiologists grade 3 to 5, and preoperative diagnosis including avascular necrosis of the hip, previous trauma, inflammatory disease, pediatric disease, and previous infection. Overall risk of IOPFF associated with age was greatest in patients below 50 years and above 80 years. Risk of any fracture reduced with computer-guided surgery and in non–National Health Service hospitals. Nonposterior approaches increased the risk of shaft and trochanteric fracture only. Cementless implants significantly increased the risk of only calcar cracks and shaft fractures and not trochanteric fractures. ConclusionFracture risk increases in patients younger than 50 and older than 80 years, females, American Society of Anesthesiologists grade 3 to 5, and indications other than primary osteoarthritis. Large cumulative reduction in IOPFF risk may occur with use of cemented implants, posterior approach, and computer-guided surgery. Level of EvidenceLevel 3b (cohort study).

Intraoperative periprosthetic femoral fractures at total hip arthroplasty. Review of classifications and treatment techniques

The review covers the problem of intraoperative periprosthetic femoral fractures at total hip arthroplasty including the causes, classification and treatment techniques. This complication may occur at any step of the intervention, may differ by localization and pattern. All these will determine the preferable surgical treatment technique.

Mortality After Periprosthetic Femur Fractures During and After Primary and Revision Total Hip Arthroplasty.

We determined mortality rates after intraoperative and postoperative periprosthetic femur fractures in primary and revision total hip arthroplasty (THA). The study population comprised 522 intraoperative and 480 postoperative femur fractures in 26,250 primary THA patients and 590 intraoperative and 224 postoperative femur fractures in 4,532 revision THA patients. The risk of death was examined using Cox regression models. In primary THA, intraoperative periprosthetic femur fractures were not associated with excess risk of death (hazard ratio, 1.03; 95% confidence interval, 0.86 to 1.22). The risk of death was slightly elevated among primary THA patients with postoperative femur fractures (hazard ratio, 1.19; 95% confidence interval, 1.08 to 1.43), but the excess risk was only confined to patients with comorbid orthopaedic conditions. In revision THA, neither intraoperative nor postoperative periprosthetic femur fractures were associated with excess risk of death. Periprosthetic femur fractures are not associated with excess mortality among primary osteoarthritis patients. Level III.

PMD26 MEDICAL RESOURCE UTILIZATION AND COSTS FOR INTRAOPERATIVE PERIPROSTHETIC HIP FRACTURES DURING TOTAL HIP ARTHROPLASTY IN THE MEDICARE POPULATION: A DIRECT AND PROPENSITY SCORE MATCHED ANALYSIS

To compare the medical resource utilization and costs among Medicare patients with intraoperative periprosthetic hip fractures (PPHFx) versus those without PPHFx during total hip arthroplasty (THA). This retrospective observational cohort study used health care claims from the United States Centers for Medicare and Medicaid Standard Analytic File (100%) sample. Patients aged 65+ with a claim for primary THA between 2010 and 2016 and a diagnosis of hip osteoarthritis (OA) were identified. Intraoperative PPHFx was defined using a combination of codes for THA and fixation or arthroplasty of hip-related procedure during THA. The comparison cohort included patients without PPHFx anytime during the one-year period. A multi-level matching technique, using direct and propensity score matching was used to balance the patient, surgeon and hospital characteristics. The proportion of patients admitted at least once to skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), readmission, outpatient hospital during the 0-90 or 0-365 day period after THA was compared as well as the total all-cause payments during those periods. A total of 4,460 patients (2,230 per cohort) were included after dual matching, mean age= 75.8 years and female= 74.4%. Utilization of any 90-day post-acute services was statistically significantly higher among patients in the PPHFx cohort versus those in the comparison cohort: SNF (41.7% vs 30.8%, P<0.0001), IRF (17.7% vs 10.1%, P<0.0001) and readmissions (17.6% vs 11.5%, P<0.0001), except outpatient hospital visit (73.1% vs 73.5%, P=0.73). The mean 90-day total all-cause payments were statistically significantly higher for patients in PPHFx cohort versus comparison ($30,114 vs $21,229, P<0.0001). All trends were similar in the 365-day follow up. Patients with intraoperative fractures had statistically significantly higher resource utilization and associated costs when compared to patients without PPHFx during THA. The statistically significant differences observed during the 90-day follow up were maintained over the one-year period.

Functional analysis of patients who underwent treatment for periprosthetic fractures following hip arthroplasty: A retrospective study

Periprosthetic fractures of the femur after hip arthroplasty represent a difficult treatment challenge. The results of management of periprosthetic fractures have varied greatly due to factors such as bone quality, fracture pattern and method of treatment including non-operative measures, reduction fixation, or revision surgery. These treatments have historically been fraught with high incidence of complications, treatment failures and compromised outcomes. Despite these problems, surgical treatment has become the standard in treating the majority of periprosthetic femur fracture. This study was to assess the functional outcome of patient who underwent treatment for periprosthetic fracture following hip arthroplasty. It is a retrospective study of 20 patients, 12 male and 8 female, with average follow up was minimum of 8 months and maximum of 24 months. Patient who underwent treatment for periprosthetic fracture following hip arthroplasty and intraoperative periprosthetic fracture were included in this study. Medically unfit patients were excluded from this study. Revision long stem, locking plate, ss wire and cable graft. Outcome was analyzed functionally by harris hip score. Our study demonstrates good functional outcome in periprosthetic fracture with few complications. Keywords: periprosthetic fracture hip, harris hip score.

Incidence, Classification, and Risk Factors for Intraoperative Periprosthetic Femoral Fractures in Patients Undergoing Total Hip Arthroplasty With a Single Stem: A Retrospective Study

BackgroundThe collum femoris preserving (CFP) stem was a specially designed femoral neck preserving component. The incidence, classification, and risk factors for intraoperative periprosthetic femoral fractures with this special stem remain unclear. MethodsThis was a retrospective study. We analyzed the clinical and radiological data of all patients who underwent primary hip arthroplasty with a CFP stem in our hospital between January 2006 and November 2018. Demographic characteristics and radiological features were obtained from the medical records and the Picture Archiving and Communication System, respectively. The incidence, Vancouver classification, and risk factors for intraoperative periprosthetic femoral fractures were identified. ResultsA total of 1633 hips were included. The incidence rate of periprosthetic femoral fractures in patients undergoing total hip arthroplasty with a CFP stem was 3.2%. According to the Vancouver classification, there were 24 patients (45.3%) with Vancouver type A fractures, 27 patients (50.9%) with Vancouver type B fractures, and 2 patients (3.8%) with Vancouver type C fractures. Five independent risk (protective) factors were found, including surgical history (odds ratio [OR] = 3.275, 95% confidence interval [CI] = 1.192-8.997), neck-shaft angle (OR = 1.104, 95% CI = 1.058-1.152), neck length preserved (OR = 0.913, 95% CI = 0.850-0.980), canal flare index (OR = 0.636, 95% CI = 0.413-0.980), and bone mineral density (OR = 0.083, 95% CI = 0.016-0.417). ConclusionThe detailed characteristics of intraoperative periprosthetic femoral fractures in patients who received a CFP stem were identified in this study. Cracks of the femoral neck and fractures on the front side of the proximal femur were more common in patients with CFP stems. As a kind of a femoral neck preserving stem, the anatomical features (eg, neck-shaft angle, preserving length) of the remaining femoral neck might influence the incidence and characteristics of intraoperative periprosthetic femoral fractures in patients with CFP stems.

Intraoperative periprosthetic fractures during total hip arthroplasty in patients with rheumatic diseases

Surgical treatment in patients with rheumatic diseases (RDs) is associated with the higher risk of complications due to the presence of the inflammatory process, to long-term therapy with glucocorticoids, disease-modifying antirheumatic drugs, and biologic agents (BA), to decreased physical activity, and the severity of functional disorders, and to obvious osteoporosis. All this increases the risk of intraoperative complications, including periprosthetic fractures.Objective: to comparatively analyze intraoperative periprosthetic fractures of the greater trochanter, acetabulum, and proximal femur during total hip arthroplasty (THA) in patients with RDs.Subjects and methods. From 1998 till 2017, a total of 1569 THA were performed in patients with RA, including 464 patients with rheumatoid arthritis (RA), 396 with juvenile rheumatoid arthritis (JRA) and systemic lupus erythematosus (SLE), and 709 with osteoarthritis (OA).Results and discussion. Periprosthetic fractures after THA were diagnosed in a total of 68 (4.33%) patients, including 23 (4.96%) patients with RA, 27 (6.82%) with JRA and SLE, and 18 (2.54%) with OA; 42 (61.8%) patients with periprosthetic fractures underwent osteosynthesis. Statistical analysis of the findings revealed significantly higher rates of complications in patients with RA and JRA with SLE (p &lt; 0.005).Conclusion. The findings confirm that the risk of periprosthetic fractures is higher in patients with inflammatory diseases, including RA, JRA, and SLE. These patients require a special approach that involves medical correction of impaired bone metabolism and proper individual selection of endoprosthetic components, by taking into account the anatomical features of female patients and delicate bone handling during surgery.

Is single-anaesthetic bilateral total hip replacement using cemented stems safe and appropriate? A review of four decades of practice.

Symptomatic bilateral hip osteoarthritis can be treated surgically with either staged or single-anaesthetic bilateral total hip replacement (BTHR). Today the typical candidate for BTHR is more likely to receive cementless implants. We present the experience of BTHR at our institution using cemented stems combined with cemented and uncemented sockets and, to our knowledge, the largest prospective single-centre series. This cohort study reviews all patients (319 patients: 638 hips) having BTHR at our institution between December 1977 and December 2015. No case was lost to follow-up. Data were collected prospectively but reviewed retrospectively. Length of stay and complication rates were included, and data were compared with Hospital Episode Statistics figures for operations carried out between March 2005 and June 2014 to confirm local database validity. Patient experience and Oxford Hip Scores were obtained for a subgroup of this cohort, comparing them with patients who underwent bilateral staged operations performed within 1 year. The rates for mortality, deep vein thrombosis, non-fatal myocardial infarction within 6 months were each 0.3% (1 episode) and non-fatal pulmonary embolism 0.6% (2 episodes). There were no intraoperative periprosthetic fractures or readmissions within 30 days. Our study shows a low risk of complications when using cemented and hybrid BTHRs for selected patients and the risk of complications compares favourably with published results. Available functional scores compared favourably to a comparison group of patients undergoing bilateral staged procedures, and a positive impression on treatment experience from a subgroup of interviewed BTHR patients was noticeable.

Towards a patient-specific estimation of intra-operative femoral fracture risk

Total Hip Arthroplasty requires pre-surgical evaluation between un-cemented and cemented prostheses. A Patient with intra-operative periprosthetic fracture and another with a successful outcome were recruited, and their finite element models were constructed by processing CT data, assuming elastic-plastic behavior of the bone as function of the local density. To resemble the insertion of the prosthesis into the femur, a fictitious thermal dilatation is applied to the broach volume. Strain-based fracture risk factor is estimated, depicting results in terms of the total mechanical strain expressed using a simple “traffic lights” color code to provide immediate, concise, and intelligible pre-operative information to surgeons.

Independent assessment and outcomes of 196 short-tapered stems short-term follow-up and review of the literature.

Longer term outcome data are now becoming available for short-tapered femoral stems for cementless total hip arthroplasty. The shorter stem has a metaphyseal fit, loading the bone in this area, leading to physiological bone remodelling. It is also bone preserving, as it is 35 mm shorter. It may be easier to insert through a smaller incision and potentially reduce complication rates. We present a retrospective single surgeon case series of 196 patients (>53% follow-up over 5 years). All patients had the cementless 'Microplasty Taperloc' (Biomet). Primary outcome measures were femoral component revision rates. Secondary outcome measures included complications, patient-reported functional outcome scores (Oxford hip) and radiographic evidence of loosening. Patients were identified using electronic software. All were routinely followed up and assessed in clinic since implant introduction in 2009. Oxford hip scores were routinely obtained. A surgeon who had not carried out the procedure independently assessed radiographs. One hundred ninety-six patients were identified. The revision rate was 0.5% due to an intraoperative peri-prosthetic fracture of the femur identified on post-operative radiograph. The complication rate was 2%, attributable to: subsidence of the prosthesis (one hip), post-operative dislocation (two hips), one of which required acetabular revision. Oxford hip scores increased on average from 21 to 45 (pre- to post-operatively). There were no signs of radiographic loosening. The results show that using the short-tapered stem is proving so far to be a reliable and safe alternative to its longer counterpart, with low complication rates in the short term.

Occult intra-operative periprosthetic fractures of the acetabulum may affect implant survival.

Occult intra-operative periprosthetic acetabular fracture is a seldom-reported complication of primary total hip arthroplasty (THA). It may potentially be associated with cup instability and implant loosening. The present study aimed to investigate clinical consequences of this complication. Between 2003 and 2012, a total of 3390 cementless total hip arthroplasties (THA) were performed at our institution. Their medical histories were retrospectively reviewed to identify all patients who received a thin-layer computer tomography (CT) scan of the pelvis including the acetabulum within the first 30 post-operative days. They were evaluated and classified by two radiologists independently with respect to the presence of recent acetabular fractures. All cases with acetabular and periacetabular fractures were included in this study. Electronic medical records were reviewed to assess implant revision. Cup stability was measured with EBRA (Einzel-Bild-Röntgen-Analyse) from plain X-rays. Periprosthetic fractures of the acetabulum were identified in 58 (50.4%) of 115 selected patients. Fractures close to but not including the acetabulum were identified in 45% (n = 26/58) of the patients, at the superolateral wall in 17% (n = 10/58), at the anterior wall of the acetabulum in 16% (n = 9/58) and in 10% (n = 6/58) each at the medial wall, and at the posterior wall respectively. One out of these 58 fractures could not be classified. Three of a total of six occult medial wall fractures had to be revised, and another two showed a high implant migration. The highest cup migration values however were found after fractures of the superolateral wall. Incomplete column fractures did not influence implant survival. Central wall acetabular fractures, although unrecognized intra- and post-operatively may impair implant survival after THA.

Technical aspects and complications in the surgical treatment of poliomyelitis-affected lower limb fractures

ObjectivePost-polio patients present problems such as small and deformed bones, with narrow intramedullary canal and osteoporosis, affecting surgical treatment. The aim of this article is to describe the main preoperative and intraoperative complications of the surgical treatment of fractures in this population. Material and methodsA retrospective analysis was conducted between 1995 and 2014. Data obtained from the medical records included patient age, fracture pattern (AO/OTA), device used, technical aspects of the surgery that changed compared to a standard procedure, and the presence of intraoperative skeletal complications. ResultsSixty-four patients with 78 fractures were included in the study. Forty-seven percent of the fractures were at the proximal femur. The main complications of hip arthroplasty (14 patients) were absent hip abductors and intraoperative instability (3), bad cup fixation (3) and intraoperative periprosthetic fracture (2). The main problems of intramedullary nailing were due to a narrow canal and previous bone deformity. Main problems reported when plating included difficulty to fit a precontoured plate, and oversized hardware. ConclusionGiven the large number of intraoperative complications, in preoperative planning we must include nails of small diameter and length, locking plates and external fixators, and, in the case of hip arthroplasty, long and thin stems and restrictive or dual mobility acetabular systems.

Risk factors and treatment of intraoperative periprosthetic acetabular fracture during total hip arthroplasty

Objective To analyze the risk factors of periprosthetic acetabular fracture in total hip arthroplasty (THA) and to discuss the prevention and management. Methods A total of 1 023 patients (1 168 hips) undergoing THA were retrospectively analyzed between January 2012 and June 2015. There were 421 males (507 hips) and 602 females (661 hips), aged from 23 to 96 years with mean age of 64.2±15.0 years. Primary total hip arthroplasty was conducted in 1 053 hips, while revision surgery was conducted in 115 hips. The reasons of periprosthetic acetabular fracture were summarized. Age, gender, BMI, primary disease, left or right sides, surgical approach, osteoporosis, prosthetic type, the coverage rate of acetabulum-bone, and the amount of surgical operation annually were compared between non-fracture and fracture. Risk factors associated with the fracture were analyzed using chi square test followed by a multivariate logistic regression. Furthermore, revision surgery was compared with primary THA using chi square test. Results The incidence of intraoperative periprosthetic acetabular fractures was 2.8% (33/1 168). The incidence of fracture was higher in revision surgery than that in primary THA (6.1% vs. 2.5%). Multivariate logistic regression showed that primary disease (developmental dysplasia of the hip and rheumatoid arthritis), osteoporosis, uncemented acetabular cup, the higher coverage rate of acetabulum-bone, and the less amount of surgical operation annually were prone to appear periprosthetic acetabular fracture in primary THA. Among the 33 patients with acetabular fractures, 13 cases (39.4%, 13/33) were found intraoperatively and 20 cases (60.6%, 20/33) postoperatively. Acetabular wall fractures were in 26 (78.8%, 26/33), column fractures in 2 (6.1%, 2/33), transverse fractures in 2 (6.1%, 2/33) and quadrilateral surface fractures with prosthetic central dislocation in 3 (9.1%, 3/33). Seven cases of 26 stable fractures and 6 cases of 7 unstable fractures were found intraoperatively. Acetabular wall fractures were fixed by additional augmentation screws or accepted no special treatment, and column fractures were fixed with plate. One quadrilateral surface fracture was accepted revision surgery using Jumbo cup, 2 quadrilateral surface fractures and 2 transverse fractures with reconstruction cage. The patients were followed up for 42.3±13.7 months (range 29-60 months). The Harris hip score was 83.3±6.6 (range 72-94) at last follow-up. No complication, such as hip dislocation, osteolysis, and prosthetic loosening was reported. Conclusion Most of periprosthetic acetabular fractures are wall fractures which could not endanger the periprosthetic stability. The detection rate of acetabular stable fracture is lower than that of unstable fracture in operation. Primary disease (developmental dysplasia of the hip and rheumatoid arthritis), osteoporosis, uncemented acetabular cup, the higher coverage rate of acetabulum-bone, the less amount of surgical operation annually are the intraoperative risk factors which closely related to acetabular fractures of primary THA. The risk of intraoperative periprosthetic acetabular fractures in revision THA is higher than that in primary THA. Key words: Arthroplasty, replacement, hip; Acetabulum; Fractures, bone; Risk factors

Intraoperative periprosthetic femur fracture during bipolar hemiarthroplasty for displaced femoral neck fractures.

We aim to review the incidence and risk factors for the development of intraoperative periprosthetic femur fractures while performing a bipolar hemiarthroplasty for displaced neck of femur fractures. Our secondary aim is to characterize the types of intraoperative periprosthetic fractures, the steps leading to the fractures, and the salvage treatments instituted. 271 patients treated with bipolar hemiarthroplasty after traumatic displaced femoral neck fractures were retrospectively analyzed. Demographic data, co-morbidities, vitamin D level, consumption of steroids, ASA score, surgical approach, surgeon experience, use of cemented or uncemented implants, proximal femur morphology, and types of anaesthesia were analyzed statistically. There were 28 patients (10.3%) with intraoperative periprosthetic femur fractures. We found two significant independent risk factors which were the use of uncemented prosthesis (OR 4.15; 95% CI 1.65-10.46; p = 0.003) and Dorr type C proximal femurs (Dorr A OR 3.6; 95% CI 1.47-8.82; p = 0.005). In addition, patients with Dorr type C proximal femurs who underwent uncemented bipolar hemiarthroplasty were more likely to sustain an intraoperative periprosthetic fracture (14(73.7%) out of 19 patients; p = 0.002). There were no significant differences found in other risk factors. The most common location for these fractures was at the greater trochanter at 11 (39.3%) cases. Majority of them, 15 (53.6%), had intraoperative fractures during trial implant insertion and reduction. The overall incidence of intraoperative periprosthetic femur fractures during hemiarthroplasty for displaced neck of femur fractures was 10.3%. The incidence was significantly higher for uncemented (14.7%) when compared to cemented prosthesis (5.4%) and the greater trochanter was the commonest area for periprosthetic fractures during trial implant insertion and reduction. Uncemented prosthesis and Dorr type C proximal femurs were two significant independent risk factors contributing to intraoperative periprosthetic fractures. By identifying these risk factors, surgeons can take ample precautions to prevent complications.

Risk of subsidence and peri-prosthetic fractures using collared hydroxyapatite-coated stem for hip arthroplasty in the elderly.

Subsidence has been noted with both cemented and uncemented stems in hip arthroplasty. On most occasions, it's minimal (i.e. less than 2 mm) and stabilises at 1 year. However, when its progressive and significant, it causes loss of length and horizontal offset, and when symptomatic warrants a revision. A retrospective radiological review of the patient database was carried out to identify all patients with age ≥ 70 years who underwent elective hip arthroplasty using uncemented HA coated collared stem and had radiographs at 1 year follow up. A total of 176 patients were identified from January 2009 to June 2010. 2 independent investigators classified the proximal femur based on Dorr type and calculated the subsidence based on Engh and Massin method of calculating the distance between the tip of greater trochanter and shoulder of the prosthesis. 7 patients (4 Bs, 2 As, 1 C) had a subsidence of ≥ 2 mm (2-3.2 mm) at 1 year. None of them was symptomatic. 1 of them was secondary to a missed calcar crack and continued to subside for 9 mm before it stabilised on the lesser trochanter at 4 years follow up. There were Dorr 22 (12.5%) type A, 147(83.5%) type B and 7(4%) type C. The mean age was 77.4 years (70-91 years) and male: female ratio was 7:15. 3 patients had an intraoperative calcar crack requiring cabling. All were mobilised full weight-bearing postoperatively, and none had a subsidence of >2 mm at 1 year follow-up. Our subgroup analysis identified that subsidence can happen when the collar is "non-functional" and the initial press fit of the stem wasn't achieved. It can also occur in an event of calcar crack, which is missed intraoperatively. In cases of calcar crack which went on to have to cable during the primary procedure, it neither changed the post-operative rehabilitation nor did it show an increased risk of subsidence. A fully hydroxyapatite (HA) coated collared stem, when used in elderly age group for elective THR, has only 2% risk of intraoperative periprosthetic fracture. There's a 4% risk of radiologically significant subsidence (i.e. ≥2 mm), however, it has not proven to be clinically significant in our study. Dorr canal type had no bearing on either risk of periprosthetic fracture or subsidence. Collared stems did not have a statistically significant difference in risk of subsidence and peri-prosthetic fracture in comparison to un-collared stem, although there was a non-significant trend in favour of collar use.

Aspectos técnicos y complicaciones en el tratamiento de las fracturas de los miembros inferiores con secuelas de poliomielitis

ObjectivePost-polio patients present problems such as small and deformed bones, with narrow intramedullary canal and osteoporosis, affecting surgical treatment. The aim of this article is to describe the main preoperative and intraoperative complications of the surgical treatment of fractures in this population. Material and methodsA retrospective analysis was conducted between 1995 and 2014. Data obtained from the medical records included patient age, fracture pattern (AO/OTA), device used, technical aspects of the surgery that changed compared to a standard procedure, and the presence of intraoperative skeletal complications. ResultsSixty-four patients with 78 fractures were included in the study. Forty-seven percent of the fractures were at the proximal femur. The main complications of hip arthroplasty (14 patients) were absent hip abductors and intraoperative instability (3), bad cup fixation (3) and intraoperative periprosthetic fracture (2). The main problems of intramedullary nailing were due to a narrow canal and previous bone deformity. Main problems reported when plating included difficulty to fit a precontoured plate, and oversized hardware. ConclusionGiven the large number of intraoperative complications, in preoperative planning we must include nails of small diameter and length, locking plates and external fixators, and, in the case of hip arthroplasty, long and thin stems and restrictive or dual mobility acetabular systems.

Revision total hip replacement using long curved fully hydroxyapatite-coated modular stems with distal interlocking

Successful femoral reconstruction in revision total hip replacement needs to address variable metadiaphyseal bone defects and still represents a controversial issue. We present our clinical experience with the use of two types of long revision, curved, fully hydroxyapatite (HA)-coated titanium femoral stems with distal interlocking. A group of 20 patients has been followed up clinically and radiographically for a period of 12.1 months (3-30 months). Indications included aseptic and septic loosening as well as adverse local tissue reactions (ALTR) to metal debris. The major complications in our series included postoperative instability and intraoperative periprosthetic femoral fracture. Revision curved modular fully HA-coated stems with distal interlocking provide for good primary stem stability and successful secondary osteointegration in revision total hip arthroplasty (THA) for both aseptic and septic loosening in the setting of femoral bone defects. Longer follow-up in a larger cohort of patients is needed to confirm the good and very good short-term results and assess femoral bone remodeling.

OSTEOPOROSIS AND JOINT REPLACEMENT

Over the past few decades, the number of implantation of endoprosthetic joint replacements has steadily increased. Many patients who need joint replacements are of older age and have a reduced bone quality due to osteoporosis. In patients with joint replacements and osteoporosis complications are often seen: intraoperative periprosthetic fractures, periprosthetic osteolysis, increased implant migration or postoperative periprosthetic fractures. The evaluation of bone quality therefore seems an essential point in patient management to provide the best possible care and to optimize long term surgical outcomes. If necessary, patients should be educated about a possible calcium and vitamin D supplementation. In addition, it seems reasonable to aim for physiological vitamin D levels perioperatively. In postmenopausal women, men over 70 years and both women and men with an increased risk of osteoporosis within two years of implantation of a total joint replacement a bone mineral density measurement should be performed. In patients with reduced bone quality, treatment with bisphosphonates, denosumab or teriparatide should be considered in order to improve the osseous integration of cementless implants, to increase the lifespan of implants as well as to reduce periprosthetic fractures and fractures in general. In individual cases of patients with osteoporosis cementation of prosthetic components (especially in total hip replacements) may be required.