Intraoperative Periprosthetic Fractures Research Articles

Intraoperative Periprosthetic Fractures Associated With Metacarpophalangeal Joint Arthroplasty

To assess the incidence of and identify risk factors for intraoperative periprosthetic fractures during primary and revision metacarpophalangeal (MCP) joint arthroplasty. Through our institutional Joint Registry Database, we identified 818 MCP joint arthroplasties performed in 285 patients from 1998 to 2012, including 690 primary arthroplasties and 128 revision arthroplasties. Primary diagnoses included inflammatory arthritis (667), osteoarthritis (75), and posttraumatic arthritis (76). Periprosthetic fractures were identified through review of medical records. Intraoperative periprosthetic fractures occurred in 23 (3%) fingers (21 patients), including 19 primary and 4 revision arthroplasties. Twelve fractures required stabilization, 4 required only bone grafting, and 1 required both. The fractures occurred during broaching (12), implantation (10), or prior implant removal (1). Diabetes mellitus (DM), younger age, pyrocarbon implant insertion, and cementless fixation increased risk for intraoperative fracture. In particular, DM and the use of pyrocarbon implants significantly increased fracture risk. At 4 years (range, 1.3-10.2 y) average follow-up, no patient with intraoperative fracture had developed a subsequent fracture compared with 3 postoperative fractures in patients without intraoperative fractures. All fractures had healed by the time of the last follow-up. The 2- and 5-year implant survival rates were 96% and 80% in those with intraoperative fractures, respectively, which was not significantly different from those without an intraoperative fracture. When comparing patients with an intraoperative fracture with those without, there was an increased risk of postoperative MCP joint instability defined as implant dislocation. Patients with intraoperative fractures still had noteworthy improvements in their postoperative pain levels and pinch strengths. Intraoperative fractures occurred in 3% of MCP joint arthroplasties, including 3% of primary and 3% of revision arthroplasties. Increased risk for fracture was associated with the use of pyrocarbon implants, cementless fixation, and DM. Although these fractures did not appear to adversely affect implant survival, they were associated with increased risk of postoperative instability. Prognostic III.

Bipolar Hemiarthroplasty for Unstable Intertrochanteric Femur Fracture in Patients over the Age of 80 Years: Comparative Analysis between Cementless and Cemented Stem

With today’s aging population, musculoskeletal diseases such as osteoporosis, degenerative arthritis, and degenerative spine disease, are on the rise, and these conditions are associated with increased fracture risk. Intertrochanteric fractures in elderly patients often involve severe displacement or comminution with poor bone quality. Accordingly, various treatment methods for hip fracture have been introduced. The incidence of fixation failure is reported to be as high as 20% in unstable intertrochanteric fracture due to nonunion, metal failure, and femoral perforation. Also postoperative ambulation may be delayed in this population due to the difficulty of achieving firm fixation. In addition, when fixation failure happens, reoperation may not be possible due to the patient’s general condition and medical complications. In comparison, bipolar hemiarthroplasty is performed as an alternative to osteosynthesis in elderly patients with unstable fracture patterns regardless of bone quality, and early ambulation is possible if stable fixation is attained. In cases of poor bone quality, cemented fixation was used in the past to enhance the initial fixation strength. A cemented stem is advantageous for stable fixation, early weight bearing, and less thigh pain, but it increases the operation time and blood loss, and complications such as cardiovascular toxicity. In the past, cementless fixation was not favored because it led to problems with initial fixation strength, bone ingrowth, subsidence of the stem and intraoperative periprosthetic fracture. However, with improvements in implant design, material, pISSN : 1226-2102, eISSN : 2005-8918 483

Intraoperative periprosthetic hip fractures

Purpose The aim of this work was to study the risk factors, clinical results, particularly the functional outcome, and radiological results for intraoperative periprosthetic fractures (PPFs) around hip arthroplasties through a retrospective analysis. Materials and methods We conducted a retrospective study based on hospital records. Patients with intraoperative PPFs around hip arthroplasties who underwent follow-up for at least 9 months were enrolled in the study. For each patient, preoperative and intraoperative risk factors were analyzed; the functional outcome in terms of the Harris hip score was compared before fracture and at the last follow-up. Results Fifteen cases were enrolled in this study. Six male and nine female patients were included with a mean ± SD age of 57.2 ± 8.5 years. A mean follow-up of 15.2 months was achieved. The average Harris hip score at the last follow-up was 85.7 points. All cases obtained primary bony union. The mean time from surgery to bony union was 8.3 months, ranging 3-12 months. Conclusion Female patients are at a higher risk of intraoperative PPF; in addition, significant femoral deformity and osteopenia are estimated risk factors. Cortical perforations and bone defects along with previously existing osteotomies are the other risk factors. Revision surgeries, cementless components, straight long stem, and vigorous manipulation of the femur are the surgery-related risk factors detected. Component stability is the most important factor for intraoperative decision-making. Extended trochanteric osteotomy is a safe and useful procedure, especially when using long straight stems. In addition, the use of supplementary cerclage fixation of fracture fragments for Vancouver B fractures yields better results.

Impaction Loads Resulting in Intraoperative Periprosthetic Femoral Fracture: A Finite Element Study

Intraoperative periprosthetic femoral fractures (IPPFF) occur in approximately 3-5% of all cementless total hip arthroplasty (THA) surgeries. This study aimed to identify the critical impaction load to cause an IPPFF during implant implementation. This critical load may be used as a guideline for surgeons as well as a parameter for the design of future surgical tools and procedures. This study concerned a single femur of a healthy 60 year old female with an anatomical femoral stem implant, thus the effects of patient specific variables (such as osteoporosis, amount of bone resorption, bone damage, implant geometry, age and gender) were not considered. The eXtended Finite Element Method (XFEM) was used to analyse the fracture. From CT scan data, a user-defined subroutine is used to assign heterogeneous isotropic material properties to the femur. It was computed that IPPFF would take place at an impaction load of 18.5 kN.

Modular Femoral Tapered Revision Stems in Total Hip Arthroplasty

Background: Modular component options can assist the surgeon in addressing complex femoral reconstructions in total hip arthroplasty by allowing for customization of version control and proximal to distal sizing. We review the early clinical results of a single modular femoral revision system that offers 3 proximal body types, 5 distal stem geometries, and a wide range of offset, sizing and auxiliary options.Methods: A query of our practice’s arthroplasty registry revealed 60 patients (61 hips) who signed an IRB-approved general research consent allowing retrospective review, and underwent total hip arthroplasty performed with the modular femoral revision system between December 2009 and April 2012. There were 35 men (58%) and 25 women (42%). Mean age was 65.1 years (range, 35-94) and BMI was 31.3 kg.m2 (range, 14-53). Procedures were complex primary in 1 hip, conversion in 6 (10%), revision in 32 (53%), and two-staged exchange for infection in 22 (33%). Two-thirds of procedures included complete acetabular revision (n=40), while 31% (19) involved liner change only and 2 were isolated femoral revisions.Results: At an average follow-up of 1.5 years (maximum: 3.7 years) there have been no revisions or failures of the femoral component. Average Harris hip scores (0 to 100 possible) improved from 44.2 preoperatively to 66.0 at most recent evaluation, while the pain component (0 to 44 possible) improved from 15.8 to 31.2. Complications requiring surgical intervention included intraoperative periprosthetic femur fracture in one patient returned to the operating suite same day for open reduction internal fixation, which further required incision and debridement for superficial infection at 1 year postoperative; and two patients with dislocation and fracture of the greater trochanter treated with open reduction, revision of the head and liner, and application of cerclage cables, one of which required removal of a migrated claw 10 months later followed 2 weeks subsequently with incision and debridement for a non-healing wound. Postoperative radiographs were available for review for 59 THA in 58 patients. Analysis of the femoral component revealed satisfactory findings in 50 hips (85%) while 9 had radiographic changes that included bone deficit, osteolysis, or radiolucency in one or more zones.Conclusions: The early results of this modular femoral revision system are promising for the treatment of the deficient femur in complex primary and revision total hip arthroplasty. Patients with radiographic changes are advised to return for regular clinical and radiographic follow-up. Survival of the modular femoral component in this series was 100% at mean follow-up of 1.5 years and up to 3.7 years. While HHS clinical and pain scores were somewhat low at most recent evaluation, they were significantly improved over preoperative levels.

Hybrid Fixation Utilizing a Custom Stem Extension for the Treatment of Periprosthetic Femoral Nonunions Around Well-Fixed Cylindrical Femoral Stems

Periprosthetic femoral nonunion associated with total hip arthroplasty is an infrequent complication1. However, the increasing worldwide incidence of periprosthetic fractures2 is expected to result in a higher number of complications, including fracture nonunion. A periprosthetic fracture around a well-fixed stem (e.g., Vancouver type B1)3 is a difficult complication to manage4, and it often requires both an arthroplasty and the skills of a trauma surgeon5. Nonunited fractures are even more challenging; they have a high rate of complications and relatively poor functional outcomes1. We present two cases of periprosthetic femoral nonunion around a stable cylindrical stem. The first nonunion occurred following an intraoperative periprosthetic fracture, and the second nonunion occurred following a postoperative fracture, after which a custom stem extension had been added to the conventional fixation method. After this combination of intramedullary and extramedullary or hybrid fixation, stability was achieved at the nonunion site, and healing was obtained in both patients. To our knowledge, the use of this type of custom-made porous-coated prosthesis has not been previously reported. The patients were informed that data concerning their cases would be submitted for publication, and they provided consent. Case 1. A sixty-six-year-old woman with a history of polymyalgia rheumatica (treated with corticosteroid therapy) and left hip osteoarthritis underwent simultaneous removal of previous fixation hardware and a cementless left total hip arthroplasty. The components included a Duraloc cup and a cylindrical-type Prodigy stem (DePuy Synthes, Warsaw, Indiana). During the procedure, the patient sustained a long spiral femoral fracture extending around and distal to the stem. Because the stem was stable, the fracture was reduced and fixed with a Dall-Miles cable and plate system and multiple lag screws. Six months postoperatively, radiographs showed a well-ingrown femoral stem; however, the fracture had failed to …

Intra-Operative Periprosthetic Fractures Associated With Press Fit Stems in Revision Total Knee Arthroplasty: Incidence, Management, and Outcomes

The purpose of this study is to report the incidence, management, and outcomes of periprosthetic fractures associated with the insertion of press-fit stems during revision total knee arthroplasty (TKA). Immediate and six week post-operative radiographs from 634 stemmed implants (307 femoral, 327 tibial) from 420 consecutive revision TKAs were reviewed. Sixteen tibial (4.9%) and 3 femoral (1%) fractures (combined incidence 3.0%) were identified. All healed uneventfully without operative intervention, with no evidence of implant loosening at a mean of 23months (range 12 to 47months). The technique of tightly press fitting stems into the diaphysis is associated with a small rate (3%) of periprosthetic fractures; most were non or minimally displaced, all healed uneventfully with non-operative management and were not associated with implant loosening.

Intraoperative Periprosthetic Femoral Fractures Related to Austin Moore Hemiarthroplasty—A Retrospective Review of 365 Patients

Intraoperative periprosthetic femoral fractures (IPFF) have been studied extensively for total hip arthroplasties, but not for hemiarthroplasties. Recent series in the literature show an IPFF rate for hemiarthroplasties ranging from 0% to 14%. The present study was designed to determine the prevalence and outcome after IPFF during non-cemented hemiarthroplasty. In addition, the surgical step at higher risk to produce these fractures was evaluated in an attempt to identify strategies that could minimize the prevalence of this complication. We performed an observational study of 365 consecutive patients undergoing and Austin-Moore hemiarthroplasty from 2005 to 2006 at our institution. The institutional IPFF rate was 6.8% (twenty-five out of 365). The moment at which the fracture was detected was collected: 1) intraoperatively and 2) in the postoperative radiological control. The surgical step in which the fracture occurred was collected: 1) neck osteotomy, 2) broaching, 3) prosthesis introduction, and 4) reduction. Results were compared to a control group according to blood transfusion rate, mortality rate and revision surgery rate. The fractures were detected during the surgery in twenty cases (80%); for the five remaining cases the fracture was only detected in the postoperative radiology. For those detected during the surgery, the two most common manouvers in which the fracture occurred was hip reduction (10 cases) and prosthesis introduction (7 cases). The blood transfusion rate, first-month mortality rate and revision surgery rate showed no statistical difference between the two groups (p = 0.3). In the present series, most of IPFF during Austin-Moore hemiarthroplasty implantation, occurred during arthroplasty reduction. Difficulties during this step should lead the surgeon to reconsider if technical mistakes are present and can be solved. However, if fracture occurs, adequate treatment of IPFF should provide satisfactory results without increasing blood transfusion needs, mortality or revision surgery.

Intraoperative periprosthetic hip fractures

Periprosthetic femoral fractures are among the most difficult and expensive complications of total hip arthroplasty. A rise in the elderly population and the increased indications of primary and revision hip arthroplasty has led to an escalating incidence. Intraoperative periprosthetic fractures are becoming more common given the increased numbers of revision total hip arthroplasty and the use of cementless fixation. Risk factors for intraoperative periprosthetic fractures include the use of minimally invasive techniques; the use of press-fit cementless stems and cups; revision surgery, specially when a long cementless stem or a short stem with impaction allografting is used; female gender; metabolic bone disease; bone diseases leading to altered morphology such as Paget disease and technical errors during the operation.

Cementless two-staged total hip arthroplasty for chronic periprosthetic infection

To determine the clinical outcomes of two-staged cementless revision arthroplasty for the treatment of deep periprosthetic infection after total hip arthroplasty. Twenty-three patients with deep periprosthetic infection treated with a standard protocol of two-staged cementless revision hip arthroplasty were enrolled in this study. There were 9 male patients and 14 female patients with an average age of 64 years (range, 52-78 years). In all cases, antibiotics-loaded cement spacers were implanted after removal of all the prosthetic components and thorough debridements had been done. All patients had a minimum of 2 weeks of intravenous antibiotics followed by 4 weeks of oral antibiotics after implant removal. After a mean interval of 6.7 months (3-28 months), revision arthroplasties were carried out with cementless femoral components followed by 2 weeks of intravenous antibiotics and 4 weeks of oral antibiotics. The mean follow-up period was (4.3±3.5) years. There were 2 cases of recurrent infections in this study. Intraoperative periprosthetic fractures were observed in 3 patients. One patient had dislocation of the implanted spacer during the interval period and 2 patients had hip dislocation after reimplantation. Mild subsidence of femoral component occurred in 1 patient. There were no cases of loosening of femoral components and cementless acetabular components in patients without infection recurrence. The Harris hip score increased from a preoperative mean of 36±13 to 85±13 at 12 months after reimplantation. Using cementless prostheses in two-staged revisions of hip periprosthetic infections can provide low rate of infection recurrence and good implant stability, but cautions must be taken when treating patients with infection caused by multidrug-resistant organisms.

The direct anterior approach in hemiarthroplasty for displaced femoral neck fractures

Hip replacement is the most common treatment for displaced femoral neck fractures in the elderly, and minimally invasive surgery is popular in the field of orthopaedic surgery. This study evaluated the outcome of monopolar hemiarthroplasty by the direct anterior approach over a postoperative period up to 2.5 years. A total of 86 patients with displaced femoral neck fractures were included (mean age of 86.5 years). Surviving patients were reviewed three months (retrospectively) and one to 2.5 years (prospectively) after surgery. One-year mortality was 36 %. For all stems, implant positioning with respect to stem alignment, restoration of leg length and femoral offset was correct. Acetabular protrusion was observed in 55 % of the patients one to 2.5 years postoperatively. Subsidence and intraoperative periprosthetic fractures occurred in three patients (3 %) each. All revision stems for postoperative periprosthetic fractures could be implanted using the initial surgical technique without extension of the previous approach. The mean Harris hip score was 85 points at the one to 2.5-year follow-up; 85 % of the patients were satisfied with their hip and 57 % returned to their preoperative level of mobility. Based on these findings, hemiarthroplasty for hip fractures can be performed safely and effectively via the direct anterior approach with good functional outcome and high patient satisfaction.

Hammering Sound Frequency Analysis and Prevention of Intraoperative Periprosthetic Fractures during Total Hip Arthroplasty

Adequate fixation at the time of cementless stem implantation depends on the operator's experience. An objective evaluation method to determine whether the stem has been appropriately implanted may be helpful. We studied the relationship between the hammering sound frequency during stem implantation and internal stress in a femoral model, and evaluated the possible usefulness of hammering sound frequency analysis for preventing intraoperative fracture. Three types of cementless stem (BiCONTACT®, SL-PLUS®, and AI-Hip®) were used. Surgeons performed stem insertion using a procedure similar to that employed in a routine operation. Stress was estimated by finite element analysis, the hammering force was measured, and frequency analysis of hammering sound data obtained using a microphone. Finite element analysis showed a decrease in the hammering sound frequency with an increase in the estimated maximum stress. When a decrease in frequency was observed, adequate hammering had occurred, and the continuation of hammering risked fracture. Based on the relationship between stress and frequency, the evaluation of changes in frequency may be useful for preventing the development of intraoperative fractures. Using our method, when a decrease in frequency is observed, the hammering force should be reduced. Hammering sound frequency analysis may allow the prediction of bone fractures that can be visually confirmed, and may be a useful objective evaluation method for the prevention of intraoperative periprosthetic fractures during stem insertion.

Uncemented hemiarthroplasty for fractured neck of femur: a consecutive series with a single prosthesis

Hemiarthroplasty of the hip is a common procedure for treatment of displaced intracapsular fractures of the femoral neck. Cementing the stem in the femur may lead to the cardiovascular complications of bone cement implantation syndrome, whereas the use of uncemented stems has been associated with an increase in intraoperative fractures. In this article, a series of 172 consecutive procedures performed with an established modular, uncemented HA-coated prosthesis are presented. There were no intraoperative deaths or periprosthetic fractures as a result of stem insertion, demonstrating that it can be used safely when an uncemented option is preferred.

The suitability of an uncemented hydroxyapatite coated (HAC) hip hemiarthroplasty stem for intra-capsular femoral neck fractures in osteoporotic elderly patients: the Metaphyseal-Diaphyseal index, a solution to preventing intra-operative periprosthetic fracture

This study will seek to identify a measurable radiographic index, the Metaphyseal-Diaphyseal Index (MDI) score to determine whether intra-operative fracture in osteoporotic bone can be predicted.A 5 year prospective cohort of 560 consecutive patients, undergoing hemiarthroplasty (cemented or uncemented), was evaluated. A nested case-control study to determine risk factors affecting intra-operative fracture was carried out.The Vancouver Classification was used to classify periprosthetic fracture.The MDI score was calculated using radiographs from the uncemented group. As a control (gold standard), Yeung et al's Canal Bone Ratio (CBR) score was also calculated. From this, a receiver operating characteristic (ROC) curve was formulated for both scores and area under the curve (AUC) compared. Intra and inter-observer correlations were determined.Cost analysis was also worked out for adverse outcomes.Four hundred and seven uncemented and one hundred and fifty-three cemented stems were implanted. The use of uncemented implants was the main risk factor for intra-operative periprosthetic fracture.Sixty-two periprosthetic fractures occurred in the uncemented group (15.2%), nine occurred in the cemented group (5.9%), P < 0.001. The revision rate for sustaining a periprosthetic fracture (uncemented group) was 17.7%, P < 0.001 and 90 day mortality 19.7%, P < 0.03.MDI's AUC was 0.985 compared to CBR's 0.948, P < 0.001. The MDI score cut-off to predict fracture was 21, sensitivity 98.3%, specificity 99.8%, positive predictive value 90.5% and negative predictive value 98%. Multivariate regression analysis ruled out any other confounding factors as being significant.The intra and inter-observer Pearson correlation scores were r = 0.99, P < 0.001.JRI uncemented hemiarthroplasty has a significantly higher intra-operative fracture rate. We recommend cemented arthroplasty for hip fractures. We propose a radiographic system that may allow surgeons to select patients who are good candidates for uncemented arthroplasty, but it needs prospective validation.

Total Hip Arthroplasty Using Two-Incision Technique

BackgroundTo evaluate the effectiveness of minimally invasive surgery total hip arthroplasty (THA) using the two-incision technique as described by Mears.MethodsFrom January 2003 to December 2006, sixty-four patients underwent total hip arthroplasty using the one-incision (group I) and two-incision (group II) technique by one surgeon. There were 34 hips in group I and 30 hips in group II. There was no difference in age, gender, and causes of THA between the two groups. We evaluated the operation time, bleeding amount, incision length, ambulation, hospital stay, and complications between the two groups.ResultsThere was no difference in the bleeding amount between the two groups. Operation time was longer in the two-incision group than in the one-incision group. Operation time of the two-incision technique could be reduced after 15 cases. Patients started ambulation after surgery earlier in group II than group I, and the hospital stay was shorter in group II than in group I. There was no difference in clinical results between the two groups. There was no difference in component position of the acetabular cup and femoral stem between the two groups. Intraoperative periprosthetic fracture occurred in four cases (13.3%) in group II.ConclusionsTwo-incision THA has the advantage of rapid recovery and shorter hospital stay. However, longer operation time and a high complication rate compared to one-incision are problems that need to be solved in the two-incision technique.

The Hazards of Total Knee Arthroplasty: A Case Report in Illustration

Infections and periprosthetic fractures are uncommon but dreaded complications of total knee arthroplasty which carry attendant morbidity and prolonged hospitalization and necessitate repeat surgery. We present a patient with a total knee arthroplasty who had both intra-operative and post-operative periprosthetic fractures who subsequently developed infection of the prosthesis necessitating revision surgery. This was complicated too by positive intra-operative tissue cultures. The clinical course, presentation and management are discussed. Total knee arthroplasty is a frequently performed and successful operation and its complications are challenging to address and require early recognition by the surgeon with appropriate referral to a dedicated arthroplasty surgeon as needed.

Two-Incision Bipolar Hemiarthroplasty for Treating Femoral Neck Fracture - Analysis of 15 Cases -

Introduction: We wanted to evaluate the efficacy of bipolar hemiarthroplasty using Berger's two-incision surgical technique for patients with muscular weakness around the hip joint and/or a high risk of dislocation. Materials and Methods: We performed bipolar hemiarthroplasty for 15 femoral neck fractures using Berger's two- incision technique between December 2005 and July 2007. The mean age of the patients was 75.2 years old. Four of them had difficulty in walking due to the sequalae after stroke and five have been treated for psychoneurologic disorders. We investigated the operation time, the length of the anterior and posterior incisions, the amount of bleeding, the time untill walking after the operation, the total hospital stay, the recovery to activities of daily living and the complications such as dislocation. Results: The mean operating time was 93 minutes. The average anterior and posterior skin incision length was 6.4 cm and 7.2 cm, respectively. The mean amount of bleeding was 420 cc at the time of surgery and 230 cc postoperatively through a drain. The patients started walking at a mean of 3.3 (1 to 5) days after the operation and the mean hospitalization was 24.3 days. Fourteen patients went back to their pre-injured activities of daily living, except one case with an intraoperative periprosthetic fracture. As for complications, two cases (13.3%) of femoral fracture were intraoperatively observed and one case of skin necrosis on the anterior incision site occurred. There were not any cases of dislocation or infection. Conclusion: Two-incision bipolar hemiarthroplasty had advantages for rehabilitation in elderly patients who have a high risk of dislocation, as well as in the patients with muscle weakness. But the operation took a long time and it had a high complication rate.

Revision Total Hip Arthroplasty Using a Wagner Revision Stem

Purpose: We evaluated the results of revision total hip arthroplasty using a Wagner revision femoral stem. Materials and Methods: We enrolled 54 patients who underwent hip arthroplasty using a Wagner revision stem between 1996 and 2004. The mean age at revision surgery was 65.4 years and the mean follow up period was 7.2 years. There were 42 aseptic loosenings and 12 periprosthetic fractures. The pre-operative femoral defects were classified according to the Paprosky classification system. Clinical and radiological results were evaluated. Results: The mean Harris hip score improved from 43 preoperatively to 89 at the latest follow up. There were 2 cases with inguinal pain and 1 with thigh pain; in each case pain was reduced by medications. All cases showed endosteal bone formation around the stem. Five cases showed radiolucency in Gruen zones 1 and 7. Six cases had hips that showed subsidence (average=3.1 mm). There was 1 dislocation (1.8%) and 1 intraoperative periprosthetic fracture (1.8%). There were no re-revisions. Conclusion: Use of a Wagner revision femoral stem for revision total hip arthroplasty elicits satisfactory results including stable fixation of the stem, a low rate of subsidence, and a low rate of dislocation.

Periprosthetic Humeral Fractures During Shoulder Arthroplasty

Currently, there is little information available on the treatment and outcome of intraoperative periprosthetic humeral fractures that occur during shoulder arthroplasty. The purpose of this study was to report on the incidence, treatment, and outcome of, as well as the risk factors for, intraoperative periprosthetic humeral fractures. Between 1980 and 2002, forty-five intraoperative periprosthetic humeral fractures occurred during shoulder arthroplasty at our institution. Twenty-eight fractures occurred during primary total shoulder arthroplasty, three occurred during primary hemiarthroplasty, and fourteen occurred during revision arthroplasty. Nineteen fractures involved the greater tuberosity, sixteen involved the humeral shaft, six involved the metaphysis, three involved the greater tuberosity and the humeral shaft, and one involved both the greater and lesser tuberosities. All patients were followed for a minimum of two years. At the time of the latest follow-up, outcomes were assessed, radiographs were examined, and relative risks were calculated. Over the twenty-two-year study period, the rate of intraoperative humeral fractures at our institution was 1.5%. All fractures healed at a mean of seventeen weeks. In the primary arthroplasty group (thirty-one patients), range of motion and pain scores improved significantly (p < 0.05) at the time of follow-up. In the revision arthroplasty group (fourteen patients), range of motion remained unchanged whereas pain scores improved significantly (p < 0.005). Transient nerve injuries occurred in six patients. Four fractures displaced postoperatively and were then treated nonoperatively; all four healed. Significant relative risks for intraoperative fracture were female sex, revision surgery, and press-fit implants (p < 0.05). The data from the present study suggest that although intraoperative humeral fractures are associated with a high rate of healing, there was a substantial rate of associated complications, including transient nerve injuries and fracture displacement. Significant risk factors for intraoperative fractures include female sex, revision surgery, and press-fit humeral implants.

Revision Total Hip Arthroplasty Using an Extensively Porous Coated Femoral Stem

BackgroundTo determine the benefit of an extensively porous coated femoral stem in patients receiving revision total hip arthroplasty.MethodsThis study reviewed the results of 35 patients who received a revision total hip arthroplasty with extensively porous coated femoral stem between August, 1996, and December, 2002. The mean follow-up period was 77.5 months. The clinical and radiological results were evaluated by the Harris hip score and serial roentgenographic findings.ResultsThe preoperative and postoperative Harris hip score was 68.3 and 92.5, respectively. Radiographically, none of the acetabular components showed any evidence of migration, tilt, rotation, or shedding of metal particles. In addition, none of the femoral components showed evidence of subsidence, pedestal, or shedding of metal particles. Twenty-two hips had a mild stress shield and 2 hips had a moderate stress shield. The perioperative complications encountered were deep vein thrombosis (1 case), mild heterotopic ossification (4 cases), intraoperative periprosthetic fractures (1 case), and nonunion of the trochanteric osteotomy site (2 cases).ConclusionsExtensively porous coated femoral stems and acetabular components produce excellent clinical and radiological results in revision total hip arthroplasty.