Periprosthetic Fracture Research Articles

Modular versus monobloc dual mobility components for primary cementless total hip arthroplasty: a systematic review and meta-analysis of implants' survival, complication rates, clinical and radiographic outcomes.

The dual mobility cup (DMC) reduces the dislocation rates in total hip arthroplasty (THA). DMC systems include anatomical (non-modular or monoblock) (ADM) and modular dual mobility (MDM) components (Stryker Orthopaedics, Mahwah, NJ, USA). This review aims to assess differences between these two types of DMC implants concerning dislocation and revision rates, as well as patient-reported outcomes. This systematic review and meta-analysis of studies reports data from patients undergoing primary THA using MDM and/or ADM implants. Following the PRISMA guidelines, we analyzed articles from Science Direct/Scopus, PubMed, and the Cochrane Database of Systematic Reviews. We compared dislocation rates, revisions for any reason, aseptic loosening, infections, fractures, and functional outcomes between ADM and MDM components. Eleven studies were considered eligible for further analysis. A total of 3369 patients (mean age = 65.4years) underwent primary THA, including 3386 DMC implants. The mean follow-up for the MDM and ADM groups was 2.9years and 3.9years, respectively. The study revealed one dislocation in the MDM and none in the ADM. By proportion metanalysis, the review did not show statistical differences in all-cause revisions (p = 0.93, [CI [0.01;0.02]) or periprosthetic fractures (p = 0.18, CI [0.01;0.02]). MDM and ADM systems, both, represent safe DM options regarding dislocation, all-causes revisions and functional outcomes.

Reoperations After Operatively and Non-Operatively Treated Periprosthetic Knee Fractures: A Nationwide Study on 1,931 Fractures After Primary Total Knee Arthroplasty.

Periprosthetic knee fracture (PPKF) following total knee arthroplasty (TKA) can be difficult to treat. A PPKF can be treated both operatively and non-operatively, and the treatment varies between fracture sites. This study aimed to assess the risk of reoperation according to the fracture site and treatment of the PPKF. This study is a nationwide cohort study using register data from 1997 to 2022. Cruciate-retaining or posterior-stabilized primary TKA were identified from the Danish Knee Arthroplasty Register (DKR). Subsequent PPKFs, fracture treatments, and later reoperations were identified through the International Classification of Diseases (ICD-10) diagnosis and procedure codes in the Danish National Patient Register. Additionally, indications for revision TKA (rTKA) in the DKR were used to identify PPKFs and the reason for reoperation. We included 1,931 PPKFs (1,494 femoral, 207 patellae, and 230 tibial) with an overall two-year reoperation risk of 20% (95% CI [confidence interval]: 18 to 23). Femoral PPKFs had a two-year reoperation risk of 16% (12 to 22) after non-operative treatment and 21% (18 to 24) after operative treatment. Patellar PPKFs had a two-year reoperation risk in five to 17 after non-operative treatment and 46% (30 to 69) after operative treatment. Tibial PPKFs had a two-year reoperation risk of 17% (11 to 27) after non-operative treatment, and 36% (25 to 53) after operative treatment. The overall two-year reoperation risk was 20% (18 to 23). Operative-treated PPKFs had a higher risk of reoperation across all fracture locations. The highest reoperation risk was found after operatively treated patella and tibial PPKFs (46 and 36%, respectively), and the lowest reoperation risk was found after non-operative treated patella PPKFs.

The effects of pre-operative anti-osteoporotic use on total joint arthroplasty complications: A national database study

BackgroundThe current study aims to analyze the effect of pre-operative non-bisphosphonate anti-osteoporotic drugs on complication and revision rates following total joint arthroplasty (TJA). MethodsA retrospective cohort analysis of the PearlDiver (PearlDiver Technologies, Colorado Springs, CO) database was performed. The database was queried to identify all patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) with history of hip or knee osteoarthritis and either osteopenia or osteoporosis. The treatment groups consisted of patients prescribed non-bisphosphonate and bisphosphonate osteomodulatory agents for 1 year prior to and following surgery. The treatment groups were matched to control cohorts by age, gender, and comorbidities. Chi-square analyses were used to compare outcomes between paired cohorts. ResultsThere were no statistically significant differences (p ≤ 0.05) in risk of aseptic loosening, broken prosthesis, dislocation of prosthetic joint, periprosthetic fracture, periprosthetic osteolysis, postoperative infection, full or partial revision, or stress fracture between both the non-bisphosphonate and bisphosphonate groups following THA or TKA. Comparisons between both groups and control cohort also yielded no significant differences. ConclusionThe current study detected no significant differences in early post-operative complications following TJA between patients treated with different classes of anti-osteoporotic medications versus untreated osteopenic/osteoporotic patients. Further research is required to fully understand the impact of osteomodulatory medications on TJA outcomes. Analysis should continue to ensure a high-quality standard of care and aim to better understand outcomes for such patients requiring TJA.

Preoperative abductor muscle strength on the healthy side affects the Timed Up and Go test after total hip arthroplasty in women

BackgroundThe risk of falls causing periprosthetic fracture has become an issue with the increase in the number of patients undergoing long-term follow-up after total hip arthroplasty (THA) and the aging of patients. The Timed Up and Go test (TUG) is utilized to evaluate fall risk. This study investigated muscle volume around the hip joint based on computed tomography (CT), CT value, and muscle strength to investigate contributing factors to poor TUG 1 year post-THA.MethodsThis study retrospectively investigated 124 patients with unilateral hip osteoarthritis who underwent THA and classified them based on TUG results at 1 year postoperatively into TUG of < 10 s (fast group [103 patients]) and ≥ 10 s (slow group [21 patients]). Body mass index, the volume and CT density of the psoas major and gluteus medius muscles on CT images, pre- and postoperative hip flexion muscle strength, and hip abductor muscle strength were compared in each group.ResultsAge was significantly older and preoperative abductor (fast Group: 1.0 ± 0.3 and slow Group: 0.7 ± 0.3, P = 0.003) and flexion muscle strengths (0.9 ± 0.3 and 0.7 ± 0.3, respectively, P = 0.02) on the healthy side were significantly lower in the slow group. The gluteus medius muscle demonstrated significantly lower CT density in the slow group on both sides. Nominal logistic regression analysis revealed that age and preoperative healthy abductor muscle strength, which are poor factors for TUG 1 year post-THA, were significantly associated with TUG of ≥ 10 s at 1 year post-THA.ConclusionsThe poor factors for TUG 1 year after THA were age and preoperative abductor muscle strength on the healthy side.

Is there a difference in pelvic and femoral morphology in early periprosthetic femoral fracture in cementless short stem total hip arthroplasty via an anterolateral approach?

BackgroundThe pelvic and femoral morphology are associated with the occurrence of early periprosthetic femoral fractures (PFFs) in cementless total hip arthroplasty (THA). Differences exist depending on the performed approach and implanted stem design. Therefore, this study was conducted to analyze the pelvic and femoral morphology in cementless short stem THA via a minimally-invasive (MIS) anterolateral approach.MethodsA retrospective, single-center, multi-surgeon, comparative propensity-score matched study of a cohort of 1826 short stem THAs was conducted. A total of 39 PFFs within the first 90 days after surgery was matched on a 2:1 ratio to non-fracture patients. The morphology of the proximal femur was analyzed with canal flare index (CFI), canal-calcar ratio (CCR), canal-bone ratio (CBR), morphological cortical index (MCI), and femoral cortical index (CI). The pelvic morphology was analyzed with ilium–ischial ratio (IR), distance anterior superior iliac spine to the tip of the greater trochanter (AGT). Both groups were analyzed regarding several parameters for femoral and pelvic morphology in non-parametric testing and univariate regression analysis.ResultsA significantly higher AGT was detected in the fracture group (104.5 mm ± 18 versus 97.4 mm ± 9.8; p = 0.016). All other femoral and pelvic parameters did not differ between both groups, also when compared depending on the Vancouver type of the PFF.ConclusionsThe morphology of the proximal femur and the pelvis do not differ in several radiological parameters in patients sustaining a PFF in cementless short stem THA via an anterolateral approach compared with matched non-fracture group. The findings are controversial to other studies with different stem types and approaches. Future studies should focus on analyzing the influence of the pelvic geometry and the shape of the proximal femur in the occurrence of PFFs in different approaches with the same stem type and vice versa.Level of Evidence Level III case-controlled study

[Translated article] Retrospective survival analysis of the use of uncemented modular tapered stems for revision in periprosthetic Vancouver B-type fractures. Is instability a threat to survival

Introduction and objectives: Periprosthetic hip fractures show increasing incidence and complexity, representing a challenge for the surgeon. We aimed to evaluate the survival of uncemented modular tapered stems in the treatment of periprosthetic Vancouver B2 and B3 type fractures and review the main complications and factors associated with decreased survival.Materials and methods: We performed a retrospective study of patients submitted to revision arthroplasty for treatment of periprosthetic femoral stem Vancouver B2 and B3 type fractures with an uncemented modular fluted tapered stem (MRP-Titan). Demographic and radiographic parameters were analyzed. The survival rate (free of reoperation) was calculated at 2- and 5-years using the Kaplan–Meier survivorship analysis.Results: Thirty-nine patients were included with a mean age of 73.5 years and a mean follow-up of 5 years. Arthroplasty survivorship at 2 years was 73.7% and at 5 years was 67.5% (mean 8.4 years; range 6.7–10.2). Survivorship was inferior in the patients with episodes of instability (mean 2.5 years; range 0–5.42) (p < 0.001). At least one episode of instability occurred in 26.3% of patients and 60% of these patients had a femoral head size 32 mm or lower. At least one episode of instability occurred in 71.4% of patients with a greater trochanter fracture (p = 0.008). The consolidation rate was 90.6% and the mortality rate was 23.7%. In the group of patients that died, 55.6% were submitted to at least one revision surgery (p = 0.044).Conclusion: Survivorship of an uncemented modular stem (MRP-Titan) in revision for PHF is significantly reduced by episodes of instability.

Anti-Osteoporotic Treatment Reduces Risk of Revision Following Total Shoulder Arthroplasty in Patients with Osteoporosis

Osteoporosis, a prevalent bone density disorder, introduces a complex dynamic in the context of total shoulder arthroplasty (TSA). However, despite the well-established association between osteoporosis and an elevated risk of revision, the existing literature lacks comprehensive insights into the impact of anti-osteoporotic therapy on surgical outcomes in the setting of TSA. Thus, the purpose of this study was to investigate whether anti-osteoporotic therapy correlates with improved revision outcomes following TSA. A retrospective cohort analysis was performed using a national all payer's claims database. Patients who underwent TSA were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) procedure codes. Patients with a preoperative diagnosis of osteoporosis were included, then stratified into two groups: (1) patients with osteoporosis who underwent anti-osteoporotic therapy within 6 months prior to surgery (Anti-OP cohort) and (2) patients with osteoporosis who never received anti-osteoporotic treatment (No Anti-OP cohort). Primary outcomes included the incidence of 2-year all-cause revision, periprosthetic fracture (PPF), periprosthetic joint infection (PJI), and mechanical loosening. Univariate and multivariable regression analysis was conducted to compare outcomes between the two cohorts. In total, 40,532 osteoporotic patients were included in this study, with 11,577 (28.5%) having undergone anti-osteoporotic treatment. Patients who did not receive anti-osteoporotic treatment had significantly higher odds of 2-year all-cause revision (Odds Ratio [OR]: 1.31; P < 0.001) and mechanical loosening (OR: 1.25; P < 0.001) following TSA when compared to those treated for osteoporosis. This study demonstrates a significant association between anti-osteoporotic therapy and reduced rates of 2-year revision following TSA. Orthopedic surgeons should recognize the heightened risk of early implant failure in the absence of osteoporosis therapy. This underscores the imperative for increased screening initiatives given the high prevalence of undiagnosed or untreated osteoporosis in the TSA population. These results also emphasize the importance of integrating osteoporosis management strategies into the broader context of surgical decision-making, thereby contributing to enhanced patient outcomes and quality of care in shoulder surgery.

Early adverse outcomes remain challenging to prevent in morbidly obese patients undergoing total hip arthroplasty.

The prevalence of obesity is increasing substantially around the world. Elevated BMI increases the risk of complications following total hip arthroplasty (THA). We sought to evaluate trends in BMI and complication rates of obese patients undergoing primary THA over the last 30 years. Through our institutional total joint registry, we identified 15,455 primary THAs performed for osteoarthritis from 1990 to 2019. Patients were categorized according to the World Health Organization (WHO) obesity classification and groups were trended over time. Cox proportional hazards regression analysis controlling for confounders was used to investigate the association between year of surgery and two-year risk of any reoperation, any revision, dislocation, periprosthetic joint infection (PJI), venous thromboembolism (VTE), and periprosthetic fracture. Regression was stratified by three separate groups: non-obese; WHO Class I and Class II (BMI 30 to 39 kg/m2); and WHO Class III patients (BMI ≥ 40 kg/m2). There was a significant increase in the proportion of all obesity classes from 1990 to 2019, and the BMI values within each WHO class significantly increased over time. Risk of any reoperation did not change over time among non-obese or WHO Class I/II patients, but increased for WHO Class III patients (hazard ratio (HR) 1.04; p = 0.044). Risk of dislocation decreased over time for non-obese (HR 0.96; p < 0.001) and WHO Class I/II (HR 0.96; p = 0.002) patients, but did not change over time for WHO Class III (HR 0.94; p = 0.073) patients. Risks of any revision and PJI did not change over time for any group. The proportion of patients undergoing THA who are obese has increased dramatically at our institution between 1990 and 2019. Despite BMI values increasing within all WHO classes over time, two-year complication risks have remained stable or decreased in WHO Class I/II patients. However, continued efforts will be required to mitigate risks in the heaviest WHO Class III patients.

Bisphosphonate Use in Patients Who Have Osteoporosis Does Not Increase the Risk of Periprosthetic Fracture Following Total Knee Arthroplasty

The purpose of this study was to evaluate the effect of preoperative bisphosphonate use in patients who have osteoporosis on the risk of complications following primary total knee arthroplasty (TKA). An administrative claims database was queried for patients who have osteoporosis undergoing primary TKA between 2010 and 2019 with a minimum of 2-year follow-up. Bisphosphonate naïve patients and bisphosphonate users, defined as patients who had a continuous prescription for bisphosphonates for a minimum of six months preoperatively, were matched 1:1 based on age, sex, and comorbidity burden. Patients undergoing non-elective TKA on chronic glucocorticoid therapy or receiving any other pharmacologic treatment for osteoporosis were excluded. The final cohort included 21,058 matched pairs of patients. The incidence of postoperative complications was identified via International Classification of Disease (ICD) coding and compared between matched groups. A subgroup analysis was performed to examine outcomes amongst patients who underwent cemented and cementless TKA. There was no difference in the incidence of periprosthetic fracture on univariate (0.7 versus 0.8%, P = 0.068) or multivariate testing (OR [odds ratio]: 1.24, 95% CI [confidence interval] [0.99 to 1.56]; P = 0.060). Bisphosphonate users were statistically less likely to undergo all-cause revision TKA at 2 years (OR: 0.84 [0.72 to 0.97]; P = 0.021). Patients who had osteoporosis were found to have an increased risk of periprosthetic fracture when TKA was performed with cementless implants (1.6 versus 0.4%; P = 0.033). However, when treated with bisphosphonates, patients who have osteoporosis demonstrated equivalent fracture rates regardless of implant type (1.3 versus 1.0%; P = 1.000). While bisphosphonate use in patients who have osteoporosis did not decrease the risk of periprosthetic fracture, it did significantly lower the incidence of all-cause revision at 2 years although the difference identified was small. Consideration should be given to performing cemented TKA in patients who have untreated osteoporosis, given the higher rate of periprosthetic fracture when cementless implants were utilized.

Resultados clínicos y radiológicos del vástago SL-Plus con un seguimiento mínimo de 10 años: un estudio retrospectivo

Purpose: The SL-Plus cementless stem was introduced in 1993 as an evolution of the Alloclassic stem with some modifications. The aim of this study was to analyse if these modifications have any influence in clinical and radiological outcomes at minimum 10-year follow-up.Methods: Sixty-eight consecutive implants (64 patients) were retrospective evaluated. The mean duration of clinical and radiographic follow-up was 12.2 years. There were 41 female and 23 male patients with a median age of 73.5 years. All complications and reinterventions were collected. Functional outcomes were assessed using the modified Harris Hip Score (mHHS). Radiographs were evaluated immediately after the operation, after a minimum 2-year follow-up and by the end of follow-up (time A, B and C, respectively).Results: Two stems were revised, one due to periprosthetic fracture and one due to aseptic loosening with a cumulative probability of not having a stem revision for any reason of 97.2% at 12.2 years. Mean mHHS was 76.7 points at the latest follow-up. Significant differences were found in distal migration (time A: 5.9mm±6.7, B: 6.9mm±7.1 and C: 8.2mm±6.3; p=0.000) and varus angulation (time A: 0.0° ±2, B: 0.0° ±2 and C: 1.0° ±3; p<0.001), although these stems showed radiographic signs of osseointegration. Thirty-three hips (48.5%) showed any radiolucent line around the stem, most of them located the proximal femur (Gruen 1 and 7). Multivariate regression analysis showed lower mHHS scores in older patients (p=0.004) and female (p=0.00).Conclusions: The modifications of the SL-Plus stem influence the long-term outcome of the implant regarding radiological results, particularly in progressive varus angulation and distal migration. However, our study has not been able to demonstrate any clinical repercussions: functional scores and survival free of all cause revision were favorable and comparable to previous reports.Level of evidence: Therapeutic Level IV (Case Series)

Effect of insurance type on Management of Vancouver B Periprosthetic Fractures: length of stay, discharge destination and cost implications.

To assess the effect of private versus public insurance on hospital length of stay, discharge destination, and costs in managing Vancouver B periprosthetic femoral fractures (PFF). A retrospective cohort study of PFF patients operatively managed at five public trauma centers. The primary outcome was hospital length of stay. Secondary outcomes included discharge destination and costs related to implants and hospital beds. The study included 195 PFF cases (133 public, 62 private). Private patients had lower ASA scores (2.8 versus 3.1, P = 0.006) and were more likely to come from independent residences (87% versus 74%, P = 0.045). Private patients spent 8 fewer days in the hospital (12 ± 8 versus 20 ± 19 days, P < 0.001) and were more often discharged to rehabilitation (74% versus 48%, P = 0.003). Public hospital costs were higher for public patients ($37 456 versus $25 324, P = 0.005), largely due to longer stays. Implant costs were similar between private and public patients, but patients that underwent revision surgeries increased costs significantly compared to patients that underwent open reduction and internal fixation alone ($6257 versus $3511, P < 0.001). Private insurance was linked to shorter hospital stays and increased discharge to rehabilitation. Public PPF patients incur an average cost of $37 456 for public hospitals, compared to $25 324 for private patients. Delays in public patient rehabilitation access may prolong hospital stays, suggesting a need for alternative care pathways, such as PPF tailored home-based rehabilitation and support programs.

Open Reduction and Internal Fixation Is a Feasible Alternative to Femoral Revision Arthroplasty in Geriatric Patients with Vancouver B2/3 Type Periprosthetic Fractures: A Study Analyzing In-Hospital Outcomes.

Purpose: The surgical management of periprosthetic femoral fractures is particularly challenging in geriatric patients due to physiological limitations. The choice between open reduction and internal fixation (ORIF) and hip revision arthroplasty for treating Vancouver B2 and B3 fractures remains controversial. This study aims to contribute further evidence by analyzing the in-hospital outcomes in geriatric patients with Vancouver B2/3 fractures. Methods: This retrospective study analyzed 133 patients treated for Vancouver B2/3 fractures at a level I trauma center from 2017 to 2023. Data were collected on preclinical characteristics, comorbidities, Vancouver classification, surgery-related parameters, and postoperative outcomes for an age- and gender-matched analysis. A subgroup analysis was also conducted on patients classified as American Society of Anesthesiologists (ASA) class 3 and 4. Results: Among the 133 patients, 85 suffered Vancouver B2 fractures and 48 Vancouver B3 fractures. Age-and-gender-matched analysis revealed that ORIF was more commonly performed in patients with higher ASA grades. A subgroup analysis of ASA 3 and 4 patients and an age-and-gender-matched analysis showed that ORIF resulted in shorter operation times and less blood loss. No significant differences were found in mortality or complication rates. Conclusions: ORIF is associated with shorter operation times, less bleeding, and comparable in-hospital outcomes in treating Vancouver B2/3 fractures in higher-risk geriatric patients compared to revision arthroplasty. The retrospective design and small sample size in the ORIF group are limitations of the study. Further studies with functional evaluation are still required.

Early weight-bearing following distal femur fracture fixation - a systematic review and meta-analysis.

The global standard of care for hip fracture surgery is early weight-bearing, but this has not extended to other lower extremity fractures in the elderly. Patients undergoing fixation of distal femur fractures are often prescribed weight-bearing restrictions, which may lead to deconditioning and other complications. The purpose of this study was to compare the outcomes and complication rates between patients permitted early versus restricted weight-bearing following distal femur fracture fixation. Medline, Embase, Cochrane and Web of Science databases were searched for English language articles up to 21 October 2023, identifying 366 studies for screening. Comparative studies evaluating patients undergoing distal femur fracture fixation with early or restricted weight-bearing were included. Native knee and periprosthetic fractures were included. Ten studies were included for analysis. Two studies provided Level II evidence, while the remaining eight studies provided Level III evidence. Cochrane risk of bias tools were utilized to assess study quality. Revision and complication rates were analyzed and reported as odds ratio. Sub-analysis was undertaken to address the heterogeneity in author definitions of weight-bearing. There was no statistically significant difference in the revision or complication rate between the two groups. Early weight-bearing following distal femur fracture fixation in a predominantly elderly population does not demonstrate an increased rate of revision or complications compared to restricted weight-bearing. However, there are limitations to the available literature, and the strength of the findings is insufficient to provide strong recommendations for all patients. Future studies should employ standardized definitions and avoid partial or time-based restrictions.

Comparative study of total hip arthroplasty with and without femoral osteotomy in Crowe Ⅳ developmental dysplasia of the hip

To compare the clinical effects of total hip arthroplasty(THA) with and without femoral osteotomy in Crowe Ⅳ developmental hip dislocation(DDH). The data on 46 patients who underwent THA for unilateral Crowe Ⅳ DDH between 2012 and 2017 were analyzed retrospectively. They were divided into two groups according to the different surgical methods. There were 24 patients in the osteotomy group, 3 males and 21 females, with an average age of (47.3±9.0) years old ranged from 34 to 57 years old;and 22 patients in the non-osteotomy group, 2 males and 20 females, with an average age of (51.6±8.3) years old ranged from 40 to 61 years old. The operative time, bleed loss, postoperative drainage volume, postoperative complications, ROM of hip, Harris hip score, limb length discrepancy(LLD), and radiological data were recorded. The femoral dislocation height and the implantation depth of sleeve were measured. All patients were followed up. The mean follow-up time was (3.8±1.2) years ranged from 2 to 6 years in the osteotomy group and (3.2±0.9) years ranged from 1 to 5 years in the non-osteotomy group. The operative time(136.8±18.9) min, bleed loss (709.8±89.4) ml, postoperative drainage volume(308.8±98.2) ml of osteotomy group were all significantly greater than those of non-osteotomy group(100.7±15.8)min, (516.5±103.3) ml, (245.3±79.3) ml (P<0.05). The Harris score at the latest follow up was significantly increased compared with preoperative score in two groups (P<0.05), but there was no significant difference between two groups (P>0.05). The LLD at last follow up was significantly increased compared with preoperative LLD in two groups, the LLD in non-osteotomy group(0.7±0.2) cm showed signifcant smaller than the two osteotomy group(1.2±0.4) cm. Between osteotomy and non-osteotomy groups, the preoperative range of motion of hip joint [(89.5±19.7) °vs (102.5±16.8) °], the preoperative height of dislocation of femoral head [(4.56±0.61) cm vs (3.10±0.73) cm], the proximal implant depth of S-ROM [(0.93±0.36) cm vs (1.67±0.28) cm] was significantly different (P<0.05). Eleven patients in the osteotomy group still had claudication, and 4 patients in the non-osteotomy group had mild claudication (P<0.05). In non-osteotomy group, 3 patients developed nerve injury (1 patient of sciatic nerve, 2 patients of femoral nerve) and 1 case developed periprosthetic fracture. In osteotomy group, 2 case of dislocation and 2 cases of periprosthetic fractures. Whether osteotomy or not can achieve satisfactory results for treating Crowe type Ⅳ DDH and significantly improve LLD. However, osteotomy is more complex and time-consuming, limb length difference is greater, and the incidence of claudication is higher. Furthermore, patients with smaller preoperative hip mobility, higher femoral dislocation, limb lengthening≥4 cm and severely narrow femoral proximal canals are prone to be peformed with subtrochanteric osteotomy.

The Use of a Novel Surgical Irrigant May Be Associated with Decreased Incidence of Surgical Site Infections

Background Periprosthetic joint infection (PJI) represents a formidable challenge to patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This investigation evaluated a novel antimicrobial surgical irrigation solution, XPerience (XP) (Next Science LLC, Jacksonville, FL), with proven high &amp; persistent in-vivo efficacy against planktonic bacteria and biofilm. The primary objective of this investigation was to compare the incidence of PJI following TKA performed with use of XP versus a standard control rinse (povidone-iodine). The secondary outcome was an all-cause return to operating room (OR) rate. Methods A retrospective cohort study was conducted from 824 consecutive patients undergoing primary THA/TKA from 12/1/2019 - 11/30/2021 treated using povidone-iodine solution and 471 consecutive patients undergoing primary THA/TKA from 12/1/2021 - 12/30/2022 treated with XP at a single institution by the senior author. All surgeries in both groups followed largely identical preoperative, perioperative, and postoperative protocols. A total of 1,295 cases were analyzed. The groups shared largely analogous background characteristics pertaining to age, sex, BMI, and American Society of Anesthesiologists (ASA) class. Results The overall SSI rate was 0% (0/471) in the XP group and 0.49% (4/824) in the control group (P = 0.3). The overall return to OR rate was 0.21% (1/471) in the XP group and 0.85% (7/824) in the control group (P = 0.3). Control group cases returned to the OR for hematoma debridements, periprosthetic fracture fixation, and PJI revisions. Conclusion This investigation is the first to remark on the clinical efficacy of a novel surgical irrigant. There was no statistically significant difference in rates of PJI or return to OR with the irrigant versus without, though a trend towards lower rates was observed in the context of a low baseline infection rate. Limitations pertaining to a single-center experience and sample size may be addressed by further studies incorporating broader enrollments.

Appropriate sagittal positioning of femoral components in total knee arthroplasty to prevent fracture and loosening.

This study aimed to investigate the optimal sagittal positioning of the uncemented femoral component in total knee arthroplasty to minimize the risk of aseptic loosening and periprosthetic fracture. Ten different sagittal placements of the femoral component, ranging from -5 mm (causing anterior notch) to +4 mm (causing anterior gap), were analyzed using finite element analysis. Both gait and squat loading conditions were simulated, and Von Mises stress and interface micromotion were evaluated to assess fracture and loosening risk. During gait, varied sagittal positioning did not lead to excessive Von Mises stress or micromotion. However, under squat conditions, posterior positioning (-4 and -5 mm) resulted in stress exceeding 150 MPa at the femoral notch, indicating potential fracture risk. Conversely, +1 mm and 0 mm sagittal positions demonstrated minimal interface micromotion. Slightly anterior sagittal positioning (+1 mm) or neutral positioning (0 mm) effectively reduced stress concentration at the femoral notch and minimized interface micromotion. Thus, these positions are deemed suitable to decrease the risk of aseptic loosening and periprosthetic femoral fracture.

Cemented Hemiarthroplasty Results in Substantial Cost Savings Over Uncemented Hemiarthroplasty for the Treatment of Femoral Neck Fractures in Patients Over 60 Years Old: A Markov Analysis

BackgroundWhile there is growing scientific evidence supporting superior outcomes following cemented versus uncemented hip hemiarthroplasty (HHA) in elderly femoral neck fractures (FNFs), the relative cost-effectiveness of this in the United States is unknown. Thus, the purpose of this study was to compare the cost-effectiveness of cemented versus uncemented HHA for the treatment of FNFs in patients > 60 years old in the United States, accounting for postoperative outcomes including periprosthetic fractures. MethodsA Markov model utilizing Monte Carlo microsimulation was developed to evaluate the outcomes and costs of patients at least 60 years of age (mean ± standard deviation, 84 ± 8 years) undergoing cemented versus uncemented HHA for the treatment of FNFs. Health utility values, transition probabilities, and upfront costs were derived from the published literature. Outcome measures included average total costs associated with each treatment (including those from patients who sustained a periprosthetic fracture), quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER). ResultsMean total costs resulting from cemented and uncemented HHA were $19,462 ± 3,581 and $21,997 ± 3,574, respectively (upfront costs from the published literature were $18,267 for cemented HHA and $16,803 for uncemented HHA). Average QALYs resulting from cemented and uncemented HHA were 4.0 ± 0.7 and 3.1 ± 0.6. The resulting ICER was -$2,688.9/QALY. Cemented HHA was found to be the most cost-effective treatment strategy in 89% of the patients in the Monte Carlo microsimulation model. ConclusionDespite documented higher upfront costs for cemented HHA, the averaged total costs over a 10-year time horizon were $2,534 less for cemented HHA than for uncemented HHA. In addition, cemented HHA resulted in an additional 0.9 QALYs relative to uncemented HHA. The findings of this United States-based study replicate the financial and quality-of-life benefits of cemented HHA for elderly FNFs seen in other health systems.

Mining and analysis of adverse event signals for alendronate based on the real-world data of FDA adverse event reporting system database

ABSTRACT Objective Our study aims to assess alendronate-related adverse events (AEs) from the US FDA adverse event reporting system database. Methods The AE data associated with alendronate between the first quarter of 2004 and the first quarter of 2024 were selected. Various signal quantification methods, including the ROR, PRR, BCPNN, and EBGM, were applied for analysis. Results In 34,943 reports where alendronate was the primary suspected drug for the AE, 24 affected system organ classes and 1046 significant preferred terms were identified in this study. Several significant AEs beyond drug instructions with strong signals were determined, including low turnover osteopathy, fracture delayed union, fracture nonunion, loss of anatomical alignment after fracture reduction, fracture malunion, periprosthetic fracture, carotid bruit, oral fibroma, traumatic occlusion, and phlebolith. The median time to onset of alendronate-related AEs was 306 days (interquartile range [IQR] 12–1,461 days), and the majority of cases occurred 2 years later (18.80%) and within 30 days (14.49%). Conclusions The current study detected multiple potential new AE signals for alendronate, and more clinical researches are required to further validate our results and clarify their associations.

Hip arthroplasty following failure of internal fixation in intertrochanteric femoral fractures: classification decision-making for femoral stem selection and clinical validation

AimsFollowing Failed Internal Fixation of Intertrochanteric Fractures (FIF-ITF), the choice of treatment remains a clinical challenge. This study introduces a novel classification system to guide the selection of femoral prostheses in hip arthroplasty (HA) and validates its clinical efficacy.MethodsRetrospectively, we analyzed 108 cases from three university-affiliated hospitals between December 2012 and February 2023 involving patients who underwent hip arthroplasty due to Failed Internal Fixation of Intertrochanteric Fractures (FIF-ITF). Patients were classified into three categories based on fracture healing, proximal femoral support, and the severity of femoral cortical defects, with subtypes identified. Surgical outcomes and complication rates were compared between the Classification-based Decision Group and the Non-classification Decision Group.ResultsThe Classification-based Decision Group did not differ significantly from the Non-classification Decision Group in operation time, blood loss, or the use of cemented stems. However, the classification system markedly reduced the risk of periprosthetic fractures intraoperatively from 22.5 to 4.4% and postoperatively from 10 to 1.4%. The Classification-based Decision Group also demonstrated higher postoperative Harris Hip Score (HHS) and Visual Analog Scale (VAS) scores.ConclusionThe proposed classification system serves as an innovative clinical tool for femoral prosthesis selection in hip arthroplasty post-FIF-ITF, effectively reducing complications and enhancing hip function in the Classification-based Decision Group, underscoring its significant clinical utility.

Predicting Proximal Humerus Fracture Mechanical Complications: Are Computed Tomography Hounsfield Units the Answer?

The purpose was to determine whether computed tomography (CT) Hounsfield units (HU) as a proxy for bone quality can predict postoperative complications following surgical treatment of proximal humerus fractures. Sixty-six patients with 2-, 3-, or 4-part proximal humerus fractures who underwent surgical fixation at single institution and had complete radiographic data available were included. Radiographic measurements included the deltoid tuberosity index (DTI) on preoperative anterior-posterior shoulder radiographs, and the HU value from the surgical proximal humerus was determined by measuring the humeral head at the midaxial/coronal/sagittal CT image using a circle-type region of interest (≥35 mm2). Postoperative complications recorded were implant failure, development of osteonecrosis, nonunion, and acute periprosthetic fracture. Patients with and without complications were statistically compared, and binary logistic regression was performed to determine whether preoperative proximal humerus CT HU were predictive of complications. Eight patients (12.1%) developed 11 overall complications, with three patients experiencing multiple complications each. Complications included osteonecrosis (4), implant failure (5), nonunion (1), and acute periprosthetic fracture (1). No difference was observed in demographics or Neer or AO/OTA classification between those with and without complications. Patients with complications had markedly lower DTI and overall HU as well as HU in the coronal and sagittal planes. Regression analysis for average DTI demonstrated a higher DTI and had a 10 times decreased risk of complication (P = 0.040, odds ratio = -10.5, 95% confidence interval, 0.000 to 0.616). Regression analysis for average total HU also found a higher HU associated with a decreased risk of complications (P = 0.034, odds ratio = -0.020, 95% confidence interval, 0.980 to 0.962). Logistic regression analysis, including age, age-adjusted Charlson Comorbidity Index, mean DTI, and mean total HU, only found mean total HU to be notable within the model. CT HU may identify patients with poorer bone quality and thus help predict postoperative complications. Diagnostic Level III.