Periprosthetic Hip Fractures Research Articles

Periprosthetic Hip Fractures With a Loose Stem: Open Reduction and Internal Fixation Versus Stem Revision

BackgroundIt is recommended revision for periprosthetic hip fractures (PPHF) with a loose stem. However, several authors have argued that under certain conditions, this fracture could be treated using osteosynthesis. The aim is to compare stem revision versus internal fixation in the treatment of PPHF with a loose stem. MethodsAll patients with PPHF with a loose stem treated by osteosynthesis and stem revision between January 2009 and January 2019 were included. We assessed hospital stay, American Society of Anesthesiologists, Charlson comorbidity index, surgery time, blood transfusion, complications, reoperation rate, first-year mortality, radiological, and functional results. ResultsA total of 57 patients were included (40 osteosyntheses and 17 stem revision), with an average follow-up time of 3.1 years. Their mean age was 78.47 years (R 45-92). In the osteosynthesis group, fewer patients required blood transfusion (32.5% vs. 70.6%), surgical times were shorter (108 minutes vs. 169 minutes), and the cost was lower, both in terms of total cost (€14,239.07 vs. €21,498.45 and operating room cost (€5014.63 vs. €8203.34). No significant differences were found between the groups in terms of complications, reoperation rate, or functional outcomes. ConclusionCompared with stem revision, osteosynthesis requires less surgery time, has a lower need for blood transfusions, and a reduced hospital cost. Stem revision remains the treatment of choice in PPHF with a loose stem, but in V-B2 fractures in elderly patients with low functional demand, high anesthetic risk (American Society of Anesthesiologists ≥3), and many comorbidities (Charlson comorbidity index ≥5) in whom anatomic reconstruction is possible, osteosynthesis can be a viable option. Evidence LevelHistorical cohorts. Level III.

Current evidence and new challenges in periprosthetic hip and knee fractures

Periprosthetic fractures (PPF) constitute an issue of increasing importance for orthopedic surgeons. With the continuous advancement of less invasive surgery techniques and the progressively ageing population, prosthetic replacement procedures have become routine. PPF are complex conditions that can compromise the outcome of surgery and the patient’s quality of life. However, in some cases, revision surgery is required. In this article we will analyze the epidemiology, risk factors, different classi ications, management, and evolution of treatment of hip and knee periprosthetic fractures.

Cortical strut allografts in salvage revision arthroplasty: Surgical technique and clinical outcomes

BackgroundThe aim of this study was to present our clinical outcomes and surgical technique in strut allografts preparation using staggered holes to enhance osteointegration and demineralised bone matrix (DBM) as an adjunct to cortical strut allografts in salvage revision arthroplasty patients. MethodsRetrospective consecutive series of patients who required strut allograft femoral reconstructions with minimum 2 years follow up between 2012 and 2018. Frozen washed irradiated, cortical struts were used and prepared adding 2 mm staggered drill holes along the length of the strut and applying DBM paste on the graft-host interface. Outcome measures included radiographic strut union, graft resorption, infection and complications. Results15 patients included; 3 males and 12 females with median age 72 years (range 60–93). All had significant bony defects (Paprosky III/IV in 12 cases including 3 cases of periprosthetic hip fractures and further 3 cases of periprosthetic knee fractures around revision hinged implants). At final follow up, median 3.8 years (range 2.7–7.2), 14/15 (93.3%) struts had united at a median 6 months (range 5–8), complete incorporation with cortical round-off was seen at median 12 months (range 8–48) in 12/15 (80%) struts, 2/15 (13.3%) show radiographic evidence of proximal minimal graft resorptions although the remainder of the strut had integrated and were asymptomatic. There were no cases of infection. ConclusionsUse of strut allografts helps to reconstruct bone defects, restore bone stock, and provide stable fixation for complex patterns of periprosthetic fractures around hip/knee implants and salvage revision cases with 93.3% union rate at median 6 months.

Particularities of hip arthroplasty and restoration of its function in patients with low bone mass (literature review)

Objective. Basing on the analysis of the scientific literature to study the prevalence of osteoporosis and osteopenia among patients with hip osteoarthritis undergoing THA and to establish the influence of osteoporosis/osteopenia on the choice of implants and on the restoration of the joint function after the surgery. Osteoporosis and osteopenia are manifested in 21–32 % patients undergoing hip arthroplasty. Low bone mass may be a cause of intraoperative (periprosthetic hip fractures) and postoperative complications. In patients with low bone mass bone remodeling with an increased resorption and inhibition of bone formation around hip components can lead to increasing of its micro-movements, the formation of fibrous tissues, and diminution of implants survivorship. In patients with normal bone mineral density (BMD) also the loss of bone tissue around the acetabular cup can occur; it can occur up to 20–60 % in the first three years post operation, which can lead to the cup instability. But the dynamics of changes in bone tissue around the acetabular component in patients with osteoporosis/osteopenia is nowadays poorly understood. We suppose that porous acetabular components have advantages in patients with low BMD. Due to the elastic modulus which is closely similar to cancellous bone, as well as the corresponding porosity, which facilitates osteointegration and gives a reliable secondary biological fixation of the acetabulum. Rehabilitation and restoration of kinematic and support function of the hip joint after arthroplasty is an important issue for patients with low BMD. Gait disturbance can persist 12 months after surgery. One of the reasons is the weakness of the muscles of the femur. Rehabilitation after total hip arthroplasty leads to faster recovery, but particularities of rehabilitation in patients with low bone mass are not fully studied.

Periprosthetic fractures of hip and knee–A morbidity and mortality analysis

BackgroundPeriprosthetic fractures (PPF) following total knee (TKA) and hip arthroplasty (THA) have become more common over the years. The aim of the present study was to assess morbidity and mortality following surgery for PPF of hip and knee. Patients and methodsAltogether, 124 patients (mean age: 77 years; 77.4% female) with PPF of the hip (n=97) and knee (n=27), treated between 2005 and 2017 at a level-1 trauma centre, were retrospectively included. In order to assess risk factors for postoperative morbidity, Fine and Gray's model was used to compensate for death as the competing event. Risk factors for mortality were estimated with uni- and multivariate Cox-regression models. ResultsVancouver B2 fractures were most common (n=39; 42.4%), followed by B1 fractures (n=23; 25.0%). Lewis-Rorabeck Type I fractures (n=14; 51.9%) were most frequent in PPF of the knee. Overall complication rates were 44.0% and 29.9% for PPF of the knee and hip, respectively, with three patients having both early and late complications, 25 patients developing early complications and 19 patients undergoing surgery for implant-related, late complications. In the multivariate Fine and Gray model, advanced patient age (HR: 0.956; 95%CI: 0.922-0.991; p=0.014) and prosthesis exchange (vs. ORIF; HR: 0.242, 95%CI: 0.068-0.859; p=0.028) were associated with lower risk of implant-related complications, irrespective of gender (p=0.450) and a surgical delay > 2 days (p=0.411). One- and 5-year overall survival-rates were 97.9% and 93.1%, respectively. Gender, type of fixation (ORIF vs. prosthesis exchange), surgical delay > 2 days, BMI and age at surgery were neither in the univariate, nor multivariate Cox-regression model associated with an increased mortality rate. ConclusionPostoperative morbidity caused by implant-related complications is higher in younger patients and those receiving ORIF. With the statistical approach used, potential underestimation of actual complication rates may have been avoided, taking into account death as the competing event. Despite being based on a retrospective, heterogenous patient collective treated at a level-1 trauma centre, our results indicate that careful planning of the surgical procedure beyond 2 days, taking into consideration both patient's age and activity level, has no negative effect on patient outcome.

Periprosthetic hip fractures: an update into their management and clinical outcomes

The Vancouver classification is still a useful tool of communication and stratification of periprosthetic fractures, but besides the three parameters it considers, clinicians should also assess additional factors.Combined advanced trauma and arthroplasty skills must be available in departments managing these complex injuries.Preoperative confirmation of the THA (total hip arthroplasty) stability is sometimes challenging. The most reliable method remains intraoperative assessment during surgical exploration of the hip joint.Certain B1 fractures will benefit from revision surgery, whilst some B2 fractures can be effectively managed with osteosynthesis, especially in frail patients.Less invasive osteosynthesis, balanced plate–bone constructs, composite implant solutions, together with an appropriate reduction of the limb axis, rotation and length are critical for a successful fixation and uneventful fracture healing.Cite this article: EFORT Open Rev 2021;6:75-92. DOI: 10.1302/2058-5241.6.200050

The Subsidence IN Centralizer (SINC) Sign: A Diagnostic Indicator to Help Prevent Missed Periprosthetic Hip Fractures.

The Subsidence IN Centralizer (SINC) Sign: A Diagnostic Indicator to Help Prevent Missed Periprosthetic Hip Fractures.

Is Timing to Surgery an Independent Risk Factor for Complications Following Operative Treatment of Periprosthetic Lower Extremity Fractures?

To identify whether timing to surgery was related to major 30-day morbidity and mortality rates in periprosthetic hip and knee fractures [OTA/AO 3 (IV.3, V.3), OTA/AO 4 (V4)]. Retrospective database review. Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Patients in the NSQIP database with periprosthetic hip or knee fractures between 2007 and 2015. Surgical management of periprosthetic hip and knee fractures including revision or open reduction internal fixation. Major 30-day morbidity and mortality after operative treatment of periprosthetic hip or knee fractures. A total of 1265 patients, mean age 72, including 883 periprosthetic hip and 382 periprosthetic fractures about the knee were reviewed. Delay in surgery greater than 72 hours is a risk factor for increased 30-day morbidity in periprosthetic hip and knee fractures [relative risk = 2.90 (95% confidence interval: 1.74-4.71); P-value ≤ 0.001] and risk factor for increased 30-day mortality [relative risk = 8.98 (95% confidence interval: 2.14-37.74); P-value = 0.003]. Using NSQIP database to analyze periprosthetic hip and knee fractures, delay to surgery is an independent risk factor for increased 30-day major morbidity and mortality when controlling for patient functional status and comorbidities. Although patient optimization and surgical planning are paramount, minimizing extended delays to surgery is a potentially modifiable risk factor in the geriatric periprosthetic lower extremity fracture patient. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Contribution of the remaining attachment index in the management of Vancouver B1 periprosthetic hip fracture

IntroductionImplant fixation assessment following Vancouver B1 periprosthetic hip fracture is a major decision factor for internal fixation and/or implant revision. The main aim of the present study was to assess the correlation between radiographic Remaining Attachment Index (RAI) and risk of implant loosening at last follow-up following internal fixation of Vancouver B1 periprosthetic hip fracture. Material and methodA multicentre retrospective study included 50 patients with Vancouver B1 periprosthetic hip fracture with uncemented femoral stem between 2013 and 2019. Preoperative radiographs were analysed independently by 2 senior orthopedic surgeons, distinguishing 2 groups: RAI>2/3 versus<2/3. Postoperative and last follow-up radiographs were then screened for signs of complete femoral component loosening. ResultsMedian age was 89 years (range: 36–99 years). Two RAI>2/3 patients showed implant loosening (8%) versus 9 RAI<2/3 patients (36%), disclosing a significant correlation between early loosening and RAI<2/3 (p=0.005). Interobserver agreement for both radiographic RAI and radiographic loosening assessment at last follow-up was 98% with kappa correlation coefficient 0.96 [range: 0.88–1]. ConclusionRemaining Attachment Index<2/3 in Vancouver B1 periprosthetic hip fracture was a risk factor for early implant loosening after isolated internal fixation. In these often frail elderly patients, first-line implant exchange is to be considered in the light of the risk/benefit ratio. The present results confirm the need for rigorous preoperative radiographic work-up of the remaining attachment area in Vancouver B1 fracture. Level of evidenceIV.

COVID-19 consent and return to elective orthopaedic surgery: allowing a true patient choice?

AimsThe exact risk to patients undergoing surgery who develop COVID-19 is not yet fully known. This study aims to provide the current data to allow adequate consent regarding the risks of post-surgery COVID-19 infection and subsequent COVID-19-related mortality.MethodsAll orthopaedic trauma cases at the Wrightington Wigan and Leigh NHS Foundation Trust from ‘lockdown’ (23 March 2020) to date (15 June 2020) were collated and split into three groups. Adult ambulatory trauma surgeries (upper limb trauma, ankle fracture, tibial plateau fracture) and regional-specific referrals (periprosthetic hip fracture) were performed at a stand-alone elective site that accepted COVID-19-negative patients. Neck of femur fractures (NOFF) and all remaining non-NOFF (paediatric trauma, long bone injury) surgeries were performed at an acute site hospital (mixed green/blue site). Patients were swabbed for COVID-19 before surgery on both sites. Age, sex, nature of surgery, American Society of Anaesthesiologists (ASA) grade, associated comorbidity, length of stay, development of post-surgical COVID-19 infection, and post-surgical COVID-19-related deaths were collected.ResultsAt the elective site, 225 patients underwent orthopaedic trauma surgery; two became COVID-19-positive (0.9%) in the immediate perioperative period, neither of which was fatal. At the acute site, 93 patients underwent non-NOFF trauma surgery, of whom six became COVID-19-positive (6.5%) and three died. A further 84 patients underwent NOFF surgery, seven becoming COVID-19 positive (8.3%) and five died.ConclusionAt the elective site, the rate of COVID-19 infection following orthopaedic trauma surgery was low, at 0.9%. At the acute mixed site (typical district general hospital), for non-NOFF surgery there was a 6.5% incidence of post-surgical COVID-19 infection (seven-fold higher risk) with 50% COVID-19 mortality; for NOFF surgery, there was an 8.3% incidence of post-surgical COVID-19 infection, with 71% COVID-19 mortality. This is likely to have significance when planning a resumption of elective orthopaedic surgery and for consent to the patient.Cite this article: Bone Joint Open 2020;1-9:556–561.

Periprosthetic Hip Fractures Outside the Initial Postoperative Period: Does Time from Diagnosis to Surgery Matter?

BackgroundDespite an increasing incidence and associated morbidity, the optimal timing for the surgical management of periprosthetic hip fractures remains unknown. This study sought to explore whether time to surgery was associated with medical or surgical complications.MethodsA retrospective review of Medicare data from 2010 to 2014 was performed using PearlDiver. All patients with a periprosthetic hip fracture greater than 90 days from surgery and undergoing open reduction internal fixation (ORIF) or revision total hip arthroplasty (RTHA) were included. Time to surgery was measured from diagnosis and dichotomized at 48 hours.ResultsOf 342 patients undergoing ORIF, 269 (79%) had surgery within 48 hours. Of 255 patients undergoing RTHA, 142 (56%) had surgery within 48 hours. For ORIF, surgery more than 48 hours after diagnosis was associated with an increased rate of 30-day deep vein thrombosis or pulmonary embolism (15% vs 7%, P = .03), which remained after adjustment (odds ratio [OR]: 2.71, 95% confidence interval [CI]: 1.11-6.45). A similar association was seen for RTHA (12% vs 6%, P = .09 and OR: 2.61, 95% CI 1.01-7.24). For RTHA, surgery more than 48 hours after diagnosis was associated with an increased rate of 90-day periprosthetic joint infection (12% vs 4%, P = .007), which remained after adjustment (OR: 3.86, 95% CI: 1.36-12.72). A similar but not significant association was seen for ORIF (7% vs 3%, P = .18 and OR: 2.65, 95% CI: 0.73-8.91).ConclusionsAmong Medicare patients with a periprosthetic hip fracture, time to surgery greater than 48 hours was associated with increased medical and surgical complications.

Is there an Increased Risk of Periprosthetic Hip Fracture with Polished Tapered Stems Implanted for Neck of Femur Fracture in the Elderly?

Is there an Increased Risk of Periprosthetic Hip Fracture with Polished Tapered Stems Implanted for Neck of Femur Fracture in the Elderly?

Modifiable risk factors for mortality in revision total hip arthroplasty for periprosthetic fracture.

The aim of this study was to identify modifiable risk factors associated with mortality in patients requiring revision total hip arthroplasty (THA) for periprosthetic hip fracture. The electronic records of consecutive patients undergoing revision THA for periprosthetic hip fracture between December 2011 and October 2018 were reviewed. The data which were collected included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, the preoperative serum level of haemoglobin, time to surgery, operating time, blood transfusion, length of hospital stay, and postoperative surgical and medical complications. Univariate and multivariate logistic regression analyses were used to determine independent modifiable factors associated with mortality at 90 days and one year postoperatively. A total of 203 patients were identified. Their mean age was 78 years (44 to 100), and 108 (53%) were female. The median time to surgery was three days (interquartile range (IQR) 2 to 5). The mortality rate at one year was 13.8% (n = 28). The commonest surgical complication was dislocation (n = 22, 10.8%) and the commonest medical complication within 90 days of surgery was hospital-acquired pneumonia (n = 25, 12%). Multivariate analysis showed that the rate of mortality one year postoperatively was five-fold higher in patients who sustained a dislocation (odds ratio (OR) 5.03 (95% confidence interval (CI) 1.60 to 15.83); p = 0.006). The rate of mortality was also four-fold higher in patients who developed hospital-acquired pneumonia within 90 days postoperatively (OR 4.43 (95% CI 1.55 to 12.67); p = 0.005). There was no evidence that the time to surgery was a risk factor for death at one year. Dislocation and hospital-acquired pneumonia following revision THA for a periprosthetic fracture are potentially modifiable risk factors for mortality. This study suggests that surgeons should consider increasing constraint to reduce the risk of dislocation, and the early involvement of a multidisciplinary team to reduce the risk of hospital-acquired pneumonia. We found no evidence that the time to surgery affected mortality, which may allow time for medical optimization, surgical planning, and resource allocation. Cite this article: Bone Joint J 2020;102-B(5):580-585.

Risk Factors for Wound Complications After Periprosthetic Fractures.

The number of hip and knee arthroplasties performed annually continues to rise. Revision rates are projected to increase by 137% to 601%, with periprosthetic fractures to be among the leading cause of revision. Wound complications following surgical treatment of periprosthetic fractures are a major source of patient morbidity and health care costs. This study evaluated risk factors for wound healing complications in patients undergoing surgical management of periprosthetic fractures around the hip and knee. This was a retrospective analysis of 67 consecutive lower-extremity periprosthetic hip and knee fracture surgeries. Descriptive data, comorbidities, dressing type, and rates of wound complications treated nonoperatively and operatively were collected. Logistic regression analysis was performed to calculate odds ratios (ORs) of having a wound complication. There was an overall wound complication rate of 22%; the majority of these complications (16%) were treated operatively. On multivariate analysis, prior bariatric surgery (OR, 12.02; 95% confidence interval [CI], 1.24-116.71; P=.03), peripheral vascular disease (OR, 6.84; 95% CI, 1.32-35.39; P=.02), and pulmonary disease (OR, 11.23; 95% CI, 1.85-68.31; P=.01) were all associated with an increased risk of developing a wound complication. Closed-incision negative-pressure therapy was associated with a decreased risk of developing a wound complication (OR, 0.04; 95% CI, 0.00-0.49, P=.01). Surgery to treat hip and knee periprosthetic fractures is associated with a high rate of wound complications. History of bariatric surgery, peripheral vascular disease, and pulmonary disease are all associated with an increased risk of developing a wound complication. Future payment models should reflect this elevated level of complications and risk. [Orthopedics. 2020;43(4):e258-e262.].

Anatomic and Patient Risk Factors for Postoperative Periprosthetic Hip Fractures: A Case-Control Study

BackgroundPeriprosthetic fracture remains a major source of reoperation following total hip arthroplasty (THA). Within 90 days of surgery, fractures may occur spontaneously or with minor injury and are therefore more likely related to patient factors including anatomic variation. MethodsFrom 2008 to 2018, 16,254 primary THAs were performed at our institution; of those, 48 were revised for periprosthetic fracture within 90 days of surgery. A control group of 193 patients undergoing THA for hip osteoarthritis (OA) was randomly selected from the source population. We excluded patients with genetic bone disease and THA performed for hip fracture. We used logistic regression to analyze associations between patient factors (demographics, anatomical factors, comorbidities, surgical technique, and implants) and odds of 90-day periprosthetic fracture. ResultsIncreased age was significantly associated with fracture (P = .002), as was female gender (P = .046). After adjusting for age and gender, absence of contralateral OA was associated with increased odds of fracture relative to patients with contralateral OA (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.60-9.29), as was having a contralateral THA in place (OR 3.70, 95% CI 1.59-8.60). The neck-shaft angle, femoral offset, and the Dorr classification were not associated with increased odds of fracture. Additionally, the distance from the tip of the trochanter to the top of the femoral head was associated with increased odds of fracture per half centimeter (OR 1.48, 95% CI 1.14-1.93). ConclusionRisk of early postoperative periprosthetic fracture following THA is increased with age, female gender, and increasing distance from the greater trochanter to the top of the femoral head; and decreased in the setting of contralateral hip OA. The trochanter-head distance correlation with periprosthetic hip fracture indicates that the preoperative anatomy may influence PPF, particularly regarding how that anatomy is reconstructed.

Clinical, functional and instrumental results of total hip arthroplasty in primary osteoarthritis

A comparative analysis of the clinical, functional and radiological results of total hip arthroplasty (THA) in pts with primary osteoarthritis (PA) was carried out. The aim was to improve the results of THA in pts with degenerative diseases of the hip joint based on the choice of the optimal type of components fixation. The study included 125 patients (68 women, 57 men) with primary coxarthritis who underwent 125 operations of unilateral THA. All pts were divided into two groups depending on the type of components fixation. Group I (N = 63; average age 69.8 ± 3.1; from 34 to 75 years) included pts with cementless fixation (DePuy, Zimmer, titanium cups, titanium stems such as Corail and Zweymuller), in group II (N = 62; average age 67.2 ± 2.7; from 44 to 87 years) — with cement fixation (Zimmer, Smith &amp; Nephew — low-profile Muller cup, Muller stem). Metal-polyethylene friction pair and head size 32 mm were used in all cases. Evaluation of the results was carried out on 2, 6 months, 1, 5, 10 years after the operation and included: functional state assessment (Harris Hip Score), radiographs analysis, as well as the frequency of complications and revision interventions. There were no significant differences in the incidence of deep periprosthetic infection, thromboembolic complications, hematomas, paraarticular ossifications, aseptic loosening, dislocations and revision interventions. There was faster positive dynamics in the early period (up to 6 months) when using cemented THA. Subsequently all the indicators were comparable in both groups. Osteolysis at the border of implant fixation was recorded in two cases in group I and in 11 cases in group II (p &lt; 0,05). In group I, eight periprosthetic intraoperative fractures of the proximal hip were recorded; in group II, this complication was obtained in one pt (p &lt; 0.05). Stress-shielding syndrome was detected in six pts from group I. This complication was not detected in group II (p &lt; 0.05). Thus, both methods are comparable in results and can be equally applicable for the surgical treatment of patients with primary osteoarthritis, which can significantly expand the possibilities of specialized medical care and effective rehabilitation of this category of patients.

A case-control study of 30-day mortality in periprosthetic hip fractures and hip fractures.

There are increasing numbers of periprosthetic femoral fractures, which have high mortality rates. These fractures occur in a similar demographic to hip fractures. There has been limited research on mortality following these fractures. This study compared 30-day mortality in periprosthetic hip fractures with case-matched hip fractures. Case notes of periprosthetic hip fractures between 1 January 2009 and 31 December 2015 were reviewed retrospectively at a single institution. There were 173 periprosthetic hip fractures over the seven years of the study. All hip fractures attending the same institution have data collected prospectively for the National Hip Fracture Database. Data were analysed from the Hip Fracture Database. A power calculation was undertaken; 173 periprosthetic hip fractures were matched to 865 hip fractures individually for age, sex, American Society of Anesthesiologists grade and capacity. The median wait to surgery was 88 hours for periprosthetic fractures and 23 hours for hip fractures (p < 0.00001); 22.5% of patients with periprosthetic fractures underwent surgery within 36 hours compared with 68.2% of those with hip fractures (p < 0.0001). The median length of stay was 16 days for periprosthetic fractures and 10 days for hip fractures (p < 0.00001). The 30-day mortality was 6.4% for periprosthetic hip fractures and 3.1% for case-matched hip fractures (odds ratio 2.11, 95% confidence interval 1.03-4.36; p = 0.043). Periprosthetic hip fractures have a significantly higher mortality than hip fractures. Further research should aim to improve outcomes in these patients.

Traumatic periprosthetic fractures in patients with total hip replacement

The incidence of periprosthetic hip fractures is increasing due to the increase in endoprosthetic hip replacements. These fractures require astaged and individual treatment concept with the aim of mobilization of the patient as early as possible. The special challenge in the diagnostics is to identify pre-existing signs of loosening of the prosthesis. When the prosthesis is still firmly fixed femoral fractures can be treated with angular stable osteosynthesis. Loosened stems usually have to be revised, mostly in combination with osteosynthesis. Fractures around the acetabulum with a fixed cup can be treated nonoperatively or with osteosynthesis, while loosened cups have to be revised. In revision surgery the stabilization of the dorsal column is crucial for a successful outcome.

Periprosthetic Femur Fractures Around a Loose Femoral Stem.

A critical component in the evaluation of a patient with a periprosthetic hip fracture is determination of stem stability. Failure to critically evaluate preoperative radiographs and subsequently intraoperative stem position may result in an incorrect treatment algorithm and early catastrophic failure of the implant construct. In 2018, this is becoming a larger issue as demand for revision total hip arthroplasty increases. Several factors contribute to the type of implant used in these fractures and depend on age, activity level, comorbidities, and available bone stock. The purpose of this article is to review the evaluation of periprosthetic hip fractures around a loose stem and provide tips and tricks for their management to allow for a successful, long-lasting outcome.

Early Morbidity but Not Mortality Increases With Surgery Delayed Greater Than 24 Hours in Patients With a Periprosthetic Fracture of the Hip

BackgroundStudies have identified a possible morbidity and mortality benefit with expedited time to surgery after a native hip fracture. This association after hip periprosthetic fractures (PPF) has been less clearly delineated. The purpose of this study is to assess the effect of time to surgery on rates of 30-day complications. MethodsThe National Surgical Quality Improvement Program registry was used to identify all patients who underwent surgical intervention for hip PPF between 2005 and 2016. Patients were stratified into 2 cohorts based on time from hospital admission to surgery, either ≤24 hours (expedited) or >24 hours (non-expedited). Thirty-day outcome variables were assessed using bivariate and multivariate analyses. ResultsWe identified 857 patients undergoing surgical intervention for hip PPF, of whom 402 (46.9%) underwent expedited surgery and 455 (53.1%) underwent non-expedited surgery. Patients with non-expedited surgery had an average time to surgery of 2.4 days (range, 1-14 days). Multivariate analysis adjusting for differences in baseline patient characteristics revealed that patients with a non-expedited procedure had higher rates of overall complications (odds ratio [OR] = 1.72; P = .014), respiratory complications (OR = 4.15; P = .0029), urinary tract infections (OR = 2.77; P = .020), nonhome discharge (OR = 2.22; P < .001), and blood transfusions (OR = 1.86; P < .001). There was no statistical difference in mortality (P = .093). Patients with non-expedited surgery also had longer total and postoperative (+2.7 days; P < .001) length of stay. ConclusionThis study did not identify any statistical difference in mortality but found an association with increased postoperative complications and non-expedited surgery for PPF. Additional prospective studies may be warranted to identify the causative factors behind this association.