Periprosthetic Hip Fractures Research Articles

Dementia and delirium, the outcomes in elderly hip fracture patients.

BackgroundDelirium in hip fractured patients is a frequent complication. Dementia is an important risk factor for delirium and is common in frail elderly. This study aimed to extend the previous knowledge on risk factors for delirium and the consequences. Special attention was given to patients with dementia and delirium.MethodsThis is a retrospective cohort study performed in the Amphia Hospital, Breda, the Netherlands. A full electronic patient file system (Hyperspace Version IU4: Epic, Inc., Verona, WI, USA) was used to assess data between January 2014 and September 2015. All patients presented were aged ≥70 years with a hip fracture, who underwent surgery with osteosynthesis or arthroplasty. Patients were excluded in case of a pathological or a periprosthetic hip fracture, multiple traumatic injuries, and high-energy trauma. Patient and surgical characteristics were documented. Postoperative outcomes were noted. Delirium was screened using Delirium Observation Screening Scale and dementia was assessed from medical notes.ResultsOf a total of 566 included patients, 75% were females. The median age was 84 years (interquartile range: 9). Delirium was observed in 35%. Significant risk factors for delirium were a high American Society of Anesthesiology score, delirium in medical history, functional dependency, preoperative institutionalization, low hemoglobin level, and high amount of blood transfusion. Delirium was correlated with a longer hospital stay (P=0.001), increased association with complications (P<0.001), institutionalization (P<0.001), and 6-month mortality (P<0.001). Patients with dementia (N=168) had a higher delirium rate (57.7%, P<0.001) but a shorter hospital stay (P<0.001). There was no significant difference in the 6-month mortality between delirious patients with (34.0%) and without dementia (26.3%).ConclusionElderly patients with a hip fracture are vulnerable for delirium, especially when the patient has dementia. Patients who underwent an episode of delirium were at increased risk for adverse outcomes.

Peri-prosthetic femoral fractures of hip or knee arthroplasty. Analysis of 34 cases and a review of Spanish series in the last 20 years

PurposeTo evaluate peri-prosthetic femoral fractures by analysing type of patient, treatment and outcomes, and to compare them with Spanish series published in the last 20 years. Material and methodsA retrospective review of the medical records of patients with peri-prosthetic femoral fractures treated in our hospital from 2010 to 2014, and telephone survey on the current status. ResultsA total of 34 peri-prosthetic femoral fractures were analysed, 20 in hip arthroplasty and 14 in knee arthroplasty. The mean age of the patients was 79.9 years, and 91% had previous comorbidity, with up to 36% having at least 3 prior systemic diseases. Mean hospital stay was 8.7 days, and was higher in surgically-treated than in conservative-treated patients. The majority (60.6%) of patients had complications, and mortality was 18%. Functional status was not regained in 61.5% of patients, and pain was higher in hip than in knee arthroplasty. DiscussionPeri-prosthetic femoral fractures are increasing in frequency. This is due to the increasing number of arthroplasties performed and also to the increasing age of these patients. Treatment of these fractures is complex because of the presence of an arthroplasty component, low bone quality, and comorbidity of the patients. ConclusionPeri-prosthetic femoral fractures impair quality of life. They need individualised treatment, and have frequent complications and mortality.

Benefit and risk in short term after total hip arthroplasty by direct anterior approach combined with dual mobility cup

No previous reports have described the benefits and risks associated with the dual mobility cup (DMC) in primary THA via direct anterior approach (DAA). The aim of this study was to compare the safety and rate of early postoperative complication of the DAA with the DMC for THA with those of the DAA with a single standard cup, and to investigate the influence of the learning curve of the use of DMC on intra- and perioperative outcomes. We retrospectively investigated 60 hips treated in the single-DAA group and 60 hips treated in the dual-DAA group. A primary/secondary outcome variable was the presence of any intra- or perioperative complication within the first 6months/the operative time and hip function at 6months postoperatively. We also analyzed influence of the learning curve of the use of DMC on intra- and perioperative outcomes. No intraoperative complications were observed in either group. One anterior dislocation and one periprosthetic hip fracture were occurred in the single-DAA group. The surgical times in the single-DAA and dual-DAA groups were 112.0±20.9 and 121.0±26.9min (p<0.001). There was no significant difference in the 6-month postoperative hip function scores between the two groups. There was no influence of the learning curve of the use of DMC on intra- and perioperative outcomes. We have demonstrated the short-term safety and lack of inferiority of using the DMC in the DAA compared with the standard single mobility cup.

Double plating in Vancouver type B1 periprosthetic proximal femur fractures: A biomechanical study.

Periprosthetic hip fractures are an increasing problem in modern orthopedic and trauma surgery. Many options for the operative treatment are available to the surgeon ranging from modern variable angular systems to standard plates, screws, and cerclages. However, there is no gold standard and therefore, the aim of this study, was to investigate the biomechanical characteristics of double plating versus a lateral standard plate in a Vancouver B1 fracture model. Ten 4th generation composite femora were used to implant cementless total hip prosthesis and create Vancouver B1 periprosthetic fractures. Afterwards, the osteotomies were fixed using the locking compression plate in combination with the locking attachment plate (LCP, LAP, DePuy Synthes, Solothurn, Switzerland)-group I. Group II additionally achieved a 5-hole 4.5/5.0 mm LCP anteriorly. Each construct was cyclically loaded to failure in axial compression. Axial construct stiffness was 50.87 N/mm (SD 1.61) for group I compared to 738.68 N/mm (SD 94.8) for group II, this difference was statistically significant (p = 0.016). The number of cycles to failure was also significant higher for group II (2,375 vs. 13,000 cycles; p = 0.016). Double plating can significantly increase construct stiffness and stability, and thus, is an option in the treatment of complex periprosthetic fractures, in revision surgery and for patients with the inability to partial weight bear. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:234-239, 2017.

Importance of revision- and tumor-endoprosthetics in the treatment of periprosthetic fractures of the lower extremity

Periprosthetic fractures of hip and knee prostheses are gaining clinical significance due to the increasing numbers of of primary arthroplasties. Additionally, these fractures are often associated with poor bone quality or present in patients after multiple revision procedures and concomitant excessive bone defects precluding those patients to be adequately treated by conventional osteosynthesis. Revision implants provide a wide range of options for the treatment of these fractures in order to achieve good clinical results. In the acetabular region cavitary defects associated with periprosthetic fractures can be treated by the use of megacups. Extensive segmental defects and pelvic discontinuity necessitate the use of cups with additional iliac support or even customized implants. Proximal femoral fractures can usually be fixed with modular stems and diaphyseal anchorage. Periprosthetic knee joint fractures can be treated with revision implants with modular sleeves or augment-combinations allowing sufficient bridging of bony defects. Functional reconstruction or refixation of the extensor mechanism is of crucial importance.

Peri-prosthetic fractures: A prevention and treatment algorithm

Risk factors for periprosthetic hip fracture include female gender, increased age, and higher ASA class. Patients with periprosthetic fractures have higher mortality, greater length of stay, and are discharged more often to extended care facilities than the general population of THA patients. Periprosthetic hip fractures can be classified based on fracture location, implant stability, and bone quality. Fractures around a stable stem can be treated with ORIF while those resulting in loss of stem stability require stem revision. Segmental replacement of the proximal femur may be necessary if proximal bone is too poor to support a revision component.

Periprosthetic fractures following total hip and knee arthroplasty: Risk factors, epidemiological aspects, diagnostics and classification systems

Periprosthetic fractures following hip and knee arthroplasty are potentially severe complications. As a fundament in diagnostic and therapeutic procedures, specific classification systems are necessary to ensure an optimal individualized treatment of these sometimes complicated fractures. This review article summarizes the epidemiological aspects, risk factors and diagnostics of periprosthetic hip and knee fractures. The most frequently used location related fracture classifications systems are explained. In addition, the recently introduced unified classification system (UCS), which is applicable to any location of periprosthetic fractures, is described in detail. Initial studies have shown a reliable applicability of the UCS to periprosthetic hip and knee fractures.

The influence of the operation technique and implant used in the treatment of periprosthetic hip and interprosthetic femur fractures: a systematic literature review of 1571 cases.

A systematic literature review on periprosthetic/interprosthetic fracture fixation after hip arthroplasties was performed to summarize available clinical data. Operation techniques and implants used were evaluated as possible risk factors for outcomes. MEDLINE and Cochrane databases were searched. Articles describing patients with postoperative periprosthetic femur fractures sustained around a hip arthroplasty and with interprosthetic fractures treated with plates, nails, screws and/or cerclage were included. Considered articles were from 2000 or newer. Eligible abstracts were screened by two independent persons and discrepancies were resolved by consensus. Absolute numbers of complications and/or reoperation events along with their corresponding rates were calculated according to operation technique and type of implant. Relative risks of having a complication and/or a reoperation according to the operation technique and the type of implant used were estimated. Available data from 49 prospective and retrospective studies were analyzed. Of 1574 fractures, 81.7% were treated with plating. For 83.0% of all fractures, an open approach was applied. The overall complication rate was 14.3%. Fixation failure and nonunion were most often reported (fixation failure: 4.4%; nonunion: 3.9%). Nonunion and refracture occurred more often after open approaches than after minimal invasive osteosynthesis (nonunion: 4.5 vs. 0.0%, p=0.001; refracture: 3.8 vs. 0.6%. p=0.024). The relative risk for nonunion was 11.9 (95% CI 4.5-31.5) times higher (p<0.0001) for non-locking plates (13.0%) than for locking plates (1.1%). The clinical evidence of published studies dealing with periprosthetic/interprosthetic fractures after hip arthroplasty is generally low. This literature search suggested higher rates of nonunion and refracture after an open approach and a higher risk of nonunion for non-locking plates compared to locking plates. Based on the available clinical evidence, no treatment recommendations can be given.

The economic impact of surgically treated peri-prosthetic hip fractures on a university teaching hospital in Wales 7.5-year study

The number of total hip replacements taking place across the UK continues to grow. In an ageing population, with people placing greater demands on their prostheses, the number of peri-prosthetic fractures is increasing. We studied the economic impact this has on a large teaching hospital.All patients with peri-prosthetic femoral fracture in a 7.5year period were identified. Radiographic and case note analysis was performed. Costings from the finance departments were obtained.90 cases were identified, 58 female and 32 male, with a mean age of 76 (range: 38–91). 89 of the cases were managed surgically, 66% undergoing revision and 33% receiving open reduction and internal fixation. According to the Vancouver Classification, 3% were Type A, 79% Type B and 18% Type C. The mean length of stay was 43days. The mean cost of management was £31,370 (range: £6885–£112,327). Patients with type C fractures had the highest mean length of stay at 53 days and mean cost of £33,417.Including rehabilitation costs, our study illustrated a mean cost of £31,370, roughly four times the current basic NHS tariff of £8552. Although implant costs are greater, treatment with revision where appropriate allows earlier weight bearing, reduced length of stay and lower overall cost.

Treatment of Vancouver type B2 periprosthetic femoral fractures.

Stem loosening in both cemented and uncemented total hip arthroplasty is the hallmark of the Vancouver type B2 classification of periprosthetic hip fractures. We discuss the technique we use at our institution for treating these fractures. Periprosthetic femoral-shaft fractures are associated with a relatively high mortality rate, approximating that of patients with hip fractures. Outcomes are directly associated with early mobilisation and construct stability. We recommend performing the procedure only when the surgeon is proficient in revision hip surgery and trauma care. A well-selected portfolio of different stem designs and an array of osteosynthesis devices should be available, as well.

A cost analysis of elective hip revision arthroplasty versus periprosthetic hip fracture management in a district general hospital

Is financing adequate for these complex cases?

Periprosthetic Fractures About the Hip: A Case-Matched Retrospective Analysis of Functional Outcomes Postrehabilitation.

Introduction:Little research has examined postrehabilitation functional outcomes of periprosthetic hip fractures. Predicted functional deficits and acceptable rehabilitation outcomes for these patients are not established. This study aimed to compare functional outcomes of periprosthetic fractures to matched patients with total hip arthroplasty (THA).Materials and Methods:Cases with periprosthetic fracture (PPF) were matched for age, gender, and surgeon to primary THA cases. Only patients who had completed at least 1 year of rehabilitation were included. Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were calculated for all surviving cases with PPF and primary THA. Secondary outcomes included length of stay and mortality. Statistical analysis was performed using Microsoft Excel and the 2-tailed Wilcoxon signed rank test. A P value of <.05 was accepted as indicative of statistical significance.Results:We identified 25 patients with PPF. Three patients were unsuitable for functional assessment. Of the cases with PPF suitable for functional assessment, 14 (14/22) were male. The median age of the PPF and the THA groups was 71 years and 68 years respectively. The median WOMAC score for the PPF group was 26 (interquartile range [IQR] 5.5-49.5) compared to that of the primary THA group, 3 (IQR 2.0-24.5; P < .05). In the PPF group, there were 7 deaths and 3 of the surviving patients had significant complications. The median length of stay in the PPF group was 13 days (IQR 10.5-35) compared to the matched group of 5 days (IQR 5-8.5; P < .05).Conclusion:Patients with PPF have markedly poorer functional outcomes than age-, gender-, and surgeon-matched patients with THA as well as prolonged length of stay. Future research should target the identification of factors that may improve functional outcomes in this growing cohort.

A New Technique in Revision Hip Arthroplasty for Vancouver B Periprosthetic Fractures

We describe a new revision technique for Vancouver B periprosthetic hip fractures that leaves the original acetabular components in situ and causes minimal damage to the hip capsule. Twenty-eight patients, average age 79, with Vancouver B periprosthetic fracture had femoral component revision using

Periprosthetic Fractures of the Acetabulum During Cup Insertion: Posterior Column Stability is Crucial

Periprosthetic hip fractures around acetabular components are rare with little information available to guide surgical management of these complex injuries. A retrospective review of intraoperative isolated acetabular periprosthetic fractures from three tertiary surgical units was done. A total of 32 patients were identified with 9 initially missed. Acetabular components were stable (type 1) in 11 patients with no failures; unstable (type 2) in 12 patients and treated with supplemental fixation. Non-union and displacement were correlated with absent posterior column plating. Missed fractures (type 3) had the highest reoperation rate. Anterior patterns all healed, whereas fractures with posterior column instability had a 67% failure rate. Periprosthetic acetabular fracture can heal successfully with posterior column stability. Plating is mandatory for large posterior wall fragments to achieve osteointegration.

Modular revision stems: how can they help us in the management of Vancouver B2 and B3 periprosthetic fractures?

Over recent years, revision stems have been introduced for the treatment of periprosthetic fractures. Modular stems are supposed to provide some advantages to the surgical treatment of this complication. To evaluate the midterm radiological and functional results of periprosthetic hip fractures treated with modular revision stems. A retrospective review of 21 patients with a mean age of 77 years (47–88) is here presented. They had suffered a periprosthetic femoral fracture around a total hip arthroplasty between 2004 and 2010. Sixteen of them were a Vancouver classification type B2 and 5 were type B3. In all cases, a transfemoral approach was performed. Previous stems were exchanged for Revitan® (Zimmer) modular stems. There were 14 curved stems and 7 straight stems. The mean patient follow-up period was 22 months. Functional results were assessed using the Merle d’Aubigne score. The degree of subsidence was determined by comparing the postoperative images with those taken during the very last follow-up. No stem loosening was observed during follow-up. There was one non-union of the femoral osteotomy which was not of either clinical or functional relevance. Subsidence was less than 4 mm in 19 cases; one case showed 7 mm of subsidence and the other had 21 mm at final follow-up. Three patients (14 %) had to be operated on again. One of them was due to a refracture, another for acetabular loosening and one more due to reiterative dislocation (an additional case of dislocation was conservatively treated). The mean Merle d’Aubigne score at final follow-up was 5-5-4. Mortality stood at 19 % throughout follow-up. Modular revision stems provide some advantages compared with osteosynthesis in that they make early weight bearing possible. In addition, version, offset, and limb length is easier to control and calculate. Therefore, modular revision stems should be considered the treatment of choice for periprosthetic femoral fractures.

AB0454 Comparative Analysis of Periprosthetic Fractures of Hip and Knee Arthroplasty in Patients with Rheumatic Diseases

BackgroundSurgical treatment of patients with rheumatic diseases (RD) is associated with increased risk of complications. It is caused presence of an inflammatory process, osteoporosis, the reduced physical activity, the severity...

Intramedullary fixation of pertrochanteric fractures after hip resurfacing arthroplasty – Do we have the answer? Case report and literature review

ObjectiveTo report a case of a peri-prosthetic hip fracture fixed using a previously unreported technique of intramedullary nailing with dual proximal fixation. Case summaryAn 81-year-old nursing home resident suffered a multi-fragmentary peri-prosthetic hip fracture around a Birmingham Hip Resurfacing arthroplasty (BHR), which was fixed using a novel technique. DiscussionSuch fractures pose a significant surgical dilemma with regards to the optimal method of treatment. The increasing popularity of these implants suggests that these fractures will become increasingly common. ConclusionWe believe that our technique provides a practical and satisfactory solution to these fractures.

Impaction Bone Grafting and Cemented Stem Revision in Periprosthetic Hip Fractures: A Novel Surgical Technique

With an ageing population, and increasing longevity of hip arthroplasty prostheses, the incidence of periprosthetic femoral fractures is rising. We present a simple and easily reproducible technique for reduction of any periprosthetic fracture that requires bone graft augmentation. This method facilitates impaction bone grafting to reconstitute lost bone stock and revision using a cemented implant.

Extracortical plate fixation with new plate inserts and cerclage wires for the treatment of periprosthetic hip fractures

Fixation of periprosthetic hip fractures with intracortical anchorage might not be feasible in cases with bulky implants and/or poor bone stock. Rotational stability of new plate inserts with extracortical anchorage for cerclage fixation was measured and compared to the stability found using a standard technique in a biomechanical setup using a torsion testing machine. In a synthetic PUR bone model, transverse fractures were fixed distally using screws and proximally by wire cerclages attached to the plates using "new" (extracortical anchorage) or "standard" (intracortical anchorage) plate inserts. Time to fracture consolidation and complications were assessed in a consecutive series of 18 patients (18female; mean age 81years, range 55-92) with periprosthetic hip fractures (ten type B1, eight type C-Vancouver) treated with the new device between July 2003 and July 2010. The "new" device showed a higher rotational stability than the "standard" technique (p < 0.001). Fractures showed radiographic consolidation after 14 ± 5weeks (mean ± SD) postoperatively in patients. Revision surgery was necessary in four patients, unrelated to the new technique. In periprosthetic hip fractures in which fixation with intracortical anchorage using conventional means might be difficult due to bulky revision stems and/or poor bone stock, the new device may be an addition to the range of existing implants.

Comment on article “Cement-in-Cement Revision for Selected Vancouver Type B1 Femoral Periprosthetic Fractures: A Biomechanical Analysis”

Comment on article “Cement-in-Cement Revision for Selected Vancouver Type B1 Femoral Periprosthetic Fractures: A Biomechanical Analysis”