Postoperative Periprosthetic Fractures Research Articles

Treatment of femoral neck fractures using actis stem: complication rate in 188 uncemented hemiarthroplasties.

Cemented hemiarthroplasty (HA) is preferred in treating dislocated femoral neck fractures in elderly, osteoporotic patients, since uncemented HA was associated with mechanical complications more frequently. Cementation can conversely cause cardiopulmonary complications, leading to demand on safe, uncemented implants addressing osteoporosis. This study is set up as a retrospective feasibility study on the use of an uncemented, collared wedge implant (Actis®, DePuy Synthes, Warsaw, IN), for HA in elderly patients, focusing on complication rate. From 1,194 patients, treated with HA in two study centers between 2017-2022, 188 received Actis® uncemented stem with bipolar head. Complete follow-up were retrospectively collected in all patients. In 188 patients (f: 64.9%; age: 83.1 ± 7.7a) included, no case of intra-operative mortality was recorded. 2day mortality was 1.1%, 30day mortality was 7.4% and 1year mortality was 28.2%. 2 (1.1%) intra-operative fractures did not receive surgical revision, 3 (1.6%) post-operative periprosthetic fractures caused separate admission and revision. 2 cases (1.1%) of early infection required surgical revision. Our data provide proof of concept, that Actis® Stem allows an alternative, uncemented treatment option for displaced femoral neck fractures with HA. In case of preoperative or intraoperative medial cortical bone defects, stability of this implant is deteriorated.

ESTIMATING THE RISK OF POSTOPERATIVE PERIPROSTHETIC FEMORAL FRACTURES AFTER TOTAL HIP ARTHROPLASTY ASSOCIATED WITH COMMONLY USED IMPLANTS: AN ANALYSIS OF NATIONAL HEALTH DATA FROM ENGLAND

Current estimates of periprosthetic fracture risk associated with femoral implants is mostly limited to revision only estimates and does not accurately represent stem performance. The aim of this study was to estimate the risk of surgically treated post-operative periprosthetic femoral fracture (POPFF) more accurately associated with frequently used femoral implants used for total hip arthroplasty (THA).A cohort study of patients who underwent primary THA in England between January 1, 2004, and December 31, 2020. Periprosthetic fractures were identified from prospectively collected revision records and national procedure coding records. Survival modelling was used to estimate POPFF incidence rates, adjusting for potential confounders. Subgroup analyses were performed for patients over 70 years, with non-osteoarthritic indications, and neck of femur fracture.POPFF occurred in 0.6% (5100/809,832) of cases during a median (IQR) follow up of 6.5 (3.9 to 9.6) years. The majority of POPFF were treated with fixation after implantation of a cemented stem. Adjusted patient time incidence rates (PTIR) for POPFF varied by stem design, regardless of cement fixation. Cemented composite beam stems (CB stems) demonstrated the lowest risk of POPFF. Collared cementless stems had an equivalent or lower rate of POPFF versus the current gold standard polished taper slip cemented stem.POPFF account for a quarter of all revisions following primary THA. Cemented CB stems are associated with the lowest POPFF risk. Stem design is strongly associated with POPFF risk, regardless of the presence of cement. Surgeons, policymakers, and patients should consider these findings when recommending femoral implants in those most at risk of POPFF.

DOES AN INTRAOPERATIVE FEMORAL FRACTURE IMPACT ONE-YEAR PATIENT-REPORTED OUTCOME MEASURES WHEN USING A CEMENTLESS CORAIL STEM?

The significance of periprosthetic fractures about a total hip arthroplasty (THA) is becoming increasingly important. Recent studies have demonstrated post-operative periprosthetic fracture rates are higher amongst cemented polished taper slip (PTS) stem designs compared to collared cementless (CC) designs.However, in the National Joint Registry, the rate of intra-operative periprosthetic femoral fractures (IOPFF) with cementless implant systems remains higher (0.87% vs 0.42%. p <0.001) potentially leading to more post-operative complications.This study identifies the incidence of IOPFF, the fracture subtype and compares functional outcomes and revision rates of CC femoral implants with an IOPFF to CC stems and PTS stems without a fracture.5376 consecutive CC stem THA, carried out through a posterior approach were reviewed for IOPFF. Each fracture was subdivided into calcar fracture, greater trochanter (GT) fracture or shaft fracture.1:1:1 matched analysis was carried out to compare Oxford scores at one year. Matching criteria included; sex (exact), age (± 1 year), American Society of Anaesthesiologists (ASA) grade (exact), and date of surgery (± 6 months).Electronic records were used to review revision rates.Following review of the CC stems, 44 (0.8%) were identified as having an IOPFF. Of these 30 (0.6%) were calcar fractures, 11 (0.2%) GT fractures and 3 (0.06%) were shaft fractures. There were no shaft penetrations.Overall, no significant difference in Oxford scores at one year were observed when comparing the CC IOPFF, CC non-IOPFF and PTS groups.There were no CC stems revised for any reason with either a calcar fracture or trochanteric fracture within the period of 8 years follow-up.IOPFF do occur more frequently in cementless systems than cemented. The majority are calcar and GT fractures. These fractures, when identified and managed intra-operatively, do not have worse functional outcomes or revision rates compared to matched non-IOPFF cases.

Evaluation of an Initial Robotic-Assisted Direct Anterior Approach Cohort Receiving a New Short Metaphyseal Filling Collared Femoral Implant

Background: Shorter, metaphyseal-filling collared stems have become popular with the direct anterior approach (DAA), based on their ease of broaching and insertion through less invasive surgical exposures. To aid with the DAA, robotic-assisted technology provides three-dimensional computed tomography (CT) preoperative planning and intraoperative guidance to accurately assess stem version. With other femoral stems, this has been shown to provide more accurate implant planning and improved patient outcomes. The purpose of this study was to understand femoral stem placement predictability and patient outcomes for a newly designed metaphyseal-filling collared stem system through a DAA in combination with a robotic-assisted system during a single surgeon’s initial cases. Materials and Methods: A single high-volume surgeon, experienced with robotic-assisted DAA total hip arthroplasty (THA), adopted the use of a metaphyseal-filling collared stem. Intraoperative data and patient outcomes up to six months postoperative were collected prospectively during the surgeon’s first 123 cases. Student’s t-tests (α=0.05) were used for statistical comparisons. Intraoperative and radiographic assessments were performed for all 123 cases. Results: The estimated version with neck-cut view of the robotic-assisted system was 13.81 ± 3.81°. The final version measurement captured with the robotic-assisted system was 16.56 ± 6.61°. The difference between the estimated version and robotic-assisted measured version was, on average, 2.68 ± 5.7° (p<0.001). The femoral stem sat at the level of the calcar in all but five cases. There were no intraoperative or postoperative periprosthetic fractures. Patients reported significant improvements in reduced Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR), Patient-Reported Outcomes Measurement Information System (PROMIS 10), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores throughout their six-month recovery process with no patients reporting a periprosthetic joint infection, fracture, or dislocation. Conclusion: The use of a metaphyseal-filling collared stem with robotic-assisted DAA resulted in adequate stem version when assessed visually and with CT scan assessments. Version estimation values were improved upon over visual assessments when using the robotic system that maps out the proximal femur and the improvement was also demonstrated when compared to the prior literature. This may also be related to the stem’s collar providing a visual guide during stem placement posterior fill of this triple-tapered stem design. Although further follow up is needed to assess longer-term outcomes, at six months postoperatively, patients had significant improvements in patient-reported outcomes with all patients reporting minimal to no restrictions with their THA.

Reliable in vitro method for the evaluation of the primary stability and load transfer of transfemoral prostheses for osseointegrated implantation.

Osseointegrated transfemoral prostheses experience aseptic complications with an incidence between 3% and 30%. The main aseptic risks are implant loosening, adverse bone remodeling, and post-operative periprosthetic fractures. Implant loosening can either be due to a lack of initial (primary) stability of the implant, which hinders bone ingrowth and therefore prevents secondary stability, or, in the long-term, to the progressive resorption of the periprosthetic bone. Post-operative periprosthetic fractures are most often caused by stress concentrations. A method to simultaneously evaluate the primary stability and the load transfer is currently missing. Furthermore, the measurement errors are seldom reported in the literature. In this study a method to reliably quantify the bone implant interaction of osseointegrated transfemoral prostheses in terms of primary stability and load transfer was developed, and its precision was quantified. Micromotions between the prosthesis and the host bone and the strains on the cortical bone were measured on five human cadaveric femurs with a typical commercial osseointegrated implant. To detect the primary stability of the implant and the load transfer, cyclic loads were applied, simulating the peak load during gait. Digital Image Correlation was used to measure displacements and bone strains simultaneously throughout the test. Permanent migrations and inducible micromotions were measured (three translations and three rotations), while, on the same specimen, the full-field strain distribution on the bone surface was measured. The repeatability tests showed that the devised method had an intra-specimen variability smaller than 6μm for the translation, 0.02 degrees for the rotations, and smaller than 60 microstrain for the strain distribution. The inter-specimen variability was larger than the intra-specimen variability due to the natural differences between femurs. Altogether, the measurement uncertainties (intrinsic measurement errors, intra-specimen repeatability and inter-specimen variability) were smaller than critical levels of biomarkers for adverse remodelling and aseptic loosening, thus allowing to discriminate between stable and unstable implants, and to detect critical strain magnitudes in the host bone. In conclusion, this work showed that it is possible to measure the primary stability and the load transfer of an osseointegrated transfemoral prosthesis in a reliable way using a combination of mechanical testing and DIC.

Management of periprosthetic humerus fractures after shoulder arthroplasty

Background The purpose of this retrospective study was to analyze time to fracture union, complications, and outcomes of postoperative periprosthetic humerus fractures after primary shoulder arthroplasty. Methods Retrospective review of patients who sustained a postoperative periprosthetic humerus fracture after primary shoulder arthroplasty at a single institution. Fractures were classified according to the Worland Classification system. Both non-operatively and operatively treated patients were included. The primary study outcomes were time to union and complications. Results There were 46 patients who sustained a postoperative periprosthetic humerus fracture after primary shoulder arthroplasty, 18 were treated non-operatively and 28 were treated operatively. There were seven (25%) patients who underwent surgery after failed non-operative management. There was only one (2.2%) patient who had a nonunion at final follow-up. The average American Shoulder and Elbow Surgeons Shoulder Score, Single Assessment Numeral Evaluation, and visual analog scale pain scores were 73.5 ± 22.7, 66.5 ± 23.1, and 2.2 ± 2.4, respectively. Conclusion There was a high rate of union for both non-operatively and operatively treated periprosthetic fractures. However, there was a high rate of cross-over from non-operative to operative treatment and a high complication rate for both cohorts. For properly indicated patients, non-operative and operative treatment can result in satisfactory patient outcomes.

Three Differing Methods of Treating Intraoperative Nondisplaced Calcar Fractures Demonstrate Similar Radiographic Stem Subsidence

BackgroundSeveral management strategies have been described to treat intraoperative calcar fractures during total hip arthroplasty (THA), including retaining the primary implant and utilizing cerclage cables (CCs) or switching the implant to one that bypasses the fracture and achieves diaphyseal fixation. However, the radiographic and clinical outcomes of these differing strategies have never been described and compared. MethodsWe retrospectively identified 50 patients who sustained an intraoperative calcar fracture out of 9,129 primary total hip arthroplasties (0.55%) performed by one of three surgeons between 2008 and 2022. Each of the three surgeons consistently employed a distinct strategy for the management of these fractures: retention of the primary metaphyseal-engaging implant and placement of CCs; exchange to a modular, tapered-fluted stem (MTF); or exchange to a fully-coated, diaphyseal-engaging stem (FC). Stem subsidence was then evaluated on standing anteroposterior pelvis radiographs at three months and one year postoperatively. Postoperative medical and surgical complication rates were evaluated. ResultsA total of fifteen patients were treated with CC, 15 with MTF, and 20 with FC. At three-month follow-up, mean stem subsidence was 0.43 ± 0.08 mm, 1.47 ± 0.36 mm, and 0.68 ± 0.39 mm for CC, MTF, and FC cohorts, respectively (P = .323). At one-year, mean stem subsidence was 0.70 ± 0.08 mm, 1.74 ± 0.69 mm, and 1.88 ± 0.90 mm for the CC, MTF, and FC cohorts, respectively (P = .485). Medical complications included 2 venous thromboembolic events (4%) within 90 days of surgery. There were 6 reoperations (12%); 3 (6%) for acute periprosthetic joint infection (all within the FC cohort); 2 (4%) for postoperative periprosthetic fractures (one fracture distal to the stem in the FC cohort and one fracture at the level of the stem in the MTF cohort), and 1 (2%) closed reduction for instability (within the CC cohort). ConclusionsThe three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence; however, the risk of reoperation was much higher than expected.

Hip & Pelvis

The February 2024 Hip & Pelvis Roundup360 looks at: Trial of vancomycin and cefazolin as surgical prophylaxis in arthroplasty; Is preoperative posterior femoral neck tilt a risk factor for fixation failure? Cemented versus uncemented hemiarthroplasty for displaced intracapsular fractures of the hip; Periprosthetic fractures in larger hydroxyapatite-coated stems: are collared stems a better alternative for total hip arthroplasty?; Postoperative periprosthetic fracture following hip arthroplasty with a polished taper slip versus composite beam stem; Is oral tranexamic acid as good as intravenous?; Stem design and the risk of early periprosthetic femur fractures following THA in elderly patients; Does powered femoral broaching compromise patient safety in total hip arthroplasty?

Reoperation risk of periprosthetic fracture after primary total hip arthroplasty using a collared cementless or a taper-slip cemented stem.

The aim of this study was to determine both the incidence of, and the reoperation rate for, postoperative periprosthetic femoral fracture (POPFF) after total hip arthroplasty (THA) with either a collared cementless (CC) femoral component or a cemented polished taper-slip (PTS) femoral component. We performed a retrospective review of a consecutive series of 11,018 THAs over a ten-year period. All POPFFs were identified using regional radiograph archiving and electronic care systems. A total of 11,018 THAs were implanted: 4,952 CC femoral components and 6,066 cemented PTS femoral components. Between groups, age, sex, and BMI did not differ. Overall, 91 patients (0.8%) sustained a POPFF. For all patients with a POPFF, 16.5% (15/91) were managed conservatively, 67.0% (61/91) underwent open reduction and internal fixation (ORIF), and 16.5% (15/91) underwent revision. The CC group had a lower POPFF rate compared to the PTS group (0.7% (36/4,952) vs 0.9% (55/6,066); p = 0.345). Fewer POPFFs in the CC group required surgery (0.4% (22/4,952) vs 0.9% (54/6,066); p = 0.005). Fewer POPFFs required surgery in males with a CC than males with a PTS (0.3% (7/2,121) vs 1.3% (36/2,674); p < 0.001). Male patients with a PTS femoral component were five times more likely to have a reoperation for POPFF. Female patients had the same incidence of reoperation with either component type. Of those having a reoperation, 80.3% (61/76) had an ORIF, which could greatly mask the size of this problem in many registries.

The Treatment of Periprosthetic Fracture Revision of the Humerus with “Bamboo Support” Structural Allograft Technique—Atrophic Non-Union of a Post-Operative Periprosthetic Fracture after Reverse Total Shoulder Arthroplasty: A Case Report

Periprosthetic fractures are a serious complication of joint replacement surgery. With the growing prevalence of reverse total shoulder arthroplasty (RTSA), the incidence of relatively uncommon periprosthetic humeral fractures has increased. Here, we present the unique case of a 74-year-old woman who developed atrophic non-union after plate osteosynthesis for a periprosthetic fracture associated with RTSA. Fixation failure was evident 3 months after the surgical intervention; the patient underwent a 3-month course of arm sling immobilization. However, bone resorption continued, and varus angulation of the fracture developed. In this case, surgical strategy involved the use of long proximal humerus internal locked system plate (DePuy Synthes, Paoli, PA, USA), augmented with autologous iliac bone graft and allogenic humerus structural bone graft with the “bamboo support technique”, fixed with Cable System (DePuy Synthes, Paoli, PA, USA). No reports have addressed the management of failed periprosthetic fractures using allogeneic humeral strut bone grafts. This report aims to fill the gap by presenting a novel surgical technique for the management of periprosthetic fractures associated with RTSA in case of treatment failure.

Controlled posterior condylar milling technique for unicompartmental knee arthroplasty minimises tibia resection during gap balancing: Short-term clinical results.

The purpose of this study was to demonstrate the clinical utility of controlled posterior condylar milling (CPCM) in gap balancing while minimally resecting the tibia during fixed-bearing unicompartmental knee arthroplasty (UKA). This study is a retrospective cohort study. Patients who underwent medial UKA for isolated medial compartment osteoarthritis with a minimum follow-up of 2 years were included. The patients were divided into two groups: the conventional group (n = 56) and the CPCM group (n = 66). In the CPCM group, the proximal tibia was resected at the level of the distal end of the subchondral bone. If the flexion gap was tighter than extension, the posterior condyle was additionally milled to adjust gap tightness. Standing knee X-ray and scanogram were used to evaluate alignment and tibia resection amount. Range of motion (ROM) and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) scores were used to evaluate clinical outcomes. The CPCM group showed significantly smaller tibia resection (3.6 ± 1.9 mm) compared to the conventional group (5.2 ± 2.7 mm) (p < 0.001). Postoperative ROM (133.0 ± 8.3°, 135.2 ± 7.2°, n.s.) and WOMAC (19.3 ± 13.6, 23.6 ± 17.7, n.s.) were not significantly different between the two groups. Postoperative periprosthetic fractures occurred in two patients in conventional group, while the CPCM group had no periprosthetic fractures. The CPCM technique may be a simple and useful intraoperative technique that can achieve minimal tibia resection and promising clinical outcomes while easily adjusting gap tightness between flexion and extension during medial fixed-bearing UKA. Level III.

Risk factors for periprosthetic femoral fracture risk around a cemented polished taper-slip stem using an osteoporotic composite bone model.

This biomechanical study aimed to determine if variations in stem material, stem geometry, stem offset and cement viscosity affect mechanical resistance to postoperative periprosthetic fracture (PFF) after hip arthroplasty with a commonly used cemented polished taper-slip (PTS) stem (CPT, Zimmer Biomet) in a novel osteoporotic composite femoral bone model. Thirty-six osteoporotic composite femoral models were tested using a standardised in-vitro loading technique to simulate a typical PFF. Outcome measures were torque to failure (N), fracture energy (N/m2) and rotation to failure (°). Comparisons were made by stem material (cobalt chrome vs stainless steel), stem geometry (CPT stem vs Exeter stem), stem offset (standard offset vs extra extended offset) and cement viscosity (high viscosity vs low viscosity). Statistical comparisons were carried out with significance set at p < 0.05. All tested samples produced clinically representative fracture patterns with varying degrees of bone and cement comminution. There was no statistically significant difference in torque to failure, fracture energy or rotation to failure between any of the compared variables (all p > 0.05). This is the first biomechanical study on mechanical resistance to PFF using osteoporotic composite bone models. For the CPT stem, it confirms that stem material, stem offset, stem geometry and cement viscosity do not affect mechanical resistance to PFF in an osteoporotic bone model.

Complication rates after direct anterior vs posterior approach for hip hemiarthroplasty in elderly individuals with femoral neck fractures.

Dislocation rates after hemiarthroplasty reportedly vary from 1% to 17%. This serious complication is associated with increased morbidity and mortality rates. Approaches to this surgery are still debated, with no consensus regarding the superiority of any single approach. To compare early postoperative complications after implementing the direct anterior and posterior approaches (PL) for hip hemiarthroplasty after femoral neck fractures. This is a comparative, retrospective, single-center cohort study conducted at a university hospital. Between March 2008 and December 2018, 273 patients (a total of 280 hips) underwent bipolar hemiarthroplasties (n = 280) for displaced femoral neck fractures using either the PL (n = 171) or the minimally invasive direct anterior approach (DAA) (n = 109). The choice of approach was related to the surgeons' practices; the implant types were similar and unrelated to the approach. Dislocation rates and other complications were reviewed after a minimum follow-up of 6 mo. Both treatment groups had similarly aged patients (mean age: 82 years), sex ratios, patient body mass indexes, and patient comorbidities. Surgical data (surgery delay time, operative time, and blood loss volume) did not differ significantly between the groups. The 30 d mortality rate was higher in the PL group (9.9%) than in the DAA group (3.7%), but the difference was not statistically significant (P = 0.052). Among the one-month survivors, a significantly higher rate of dislocation was observed in the PL group (14/154; 9.1%) than in the DAA group (0/105; 0%) (P = 0.002). Of the 14 patients with dislocation, 8 underwent revision surgery for recurrent instability (posterior group), and one of them had 2 additional procedures due to a deep infection. The rate of other complications (e.g., perioperative and early postoperative periprosthetic fractures and infection-related complications) did not differ significantly between the groups. These findings suggest that the DAA to bipolar hemiarthroplasty for patients with femoral neck fractures is associated with a lower dislocation rate (< 1%) than the PL.

A high risk of postoperative periprosthetic femoral fracture in Dorr type C femurs: a retrospective cohort study with 10-year follow-up data and a preliminary monochromatic image analysis.

The authors applied Anatomique Benoist Girard II (ABG II) stems for total hip arthroplasty in some Dorr type C femurs as early attempts. Here, the authors compared the long-term follow-up results between ABG II stems and the 'well-performing' Corail stems and their monochromatic images. Among 3214 primary total hip arthroplasty records, 43 short ABG II stems and 67 standard-length Corail stems implanted in Dorr type C femurs were eligible and enrolled in this retrospective cohort study, with a mean follow-up of 10.3 years. Revision rates, Harris hip scores, and radiologic signs were compared. Spectral CT scans from a representative sample were obtained, and monochromatic images were reconstructed. A quantitative method was developed to measure the volume of the gap around stems. Patient-specific finite element analysis was conducted to investigate the strains. The revision rate of ABG II stems was significantly higher than that of Corail stems (21 vs. 3%, P <0.05). In the monochromatic images, fewer spot-weld signs (2.2 vs. 3.4, P <0.05) and wider gaps around stems (1.64cm 3 vs. 0.13cm 3 , P <0.05) were observed on average in the ABG II group. The mean maximum principal strains of the proximal femurs in the ABG II group were close to the yield strains and significantly larger than those in the Corail group (0.0052 vs. 0.0011, P <0.05). There was a high risk of postoperative periprosthetic femoral fracture for ABG II stems in Dorr type C femurs. Monochromatic images provided some insight into the failure mechanism. III.

Cemented femoral stem design and postoperative periprosthetic fracture risk following total hip arthroplasty.

Polished taper-slip (PTS) cemented stems have an excellent clinical track record and are the most common stem type used in primary total hip arthroplasty (THA) in the UK. Due to low rates of aseptic loosening, they have largely replaced more traditional composite beam (CB) cemented stems. However, there is now emerging evidence from multiple joint registries that PTS stems are associated with higher rates of postoperative periprosthetic femoral fracture (PFF) compared to their CB stem counterparts. The risk of both intraoperative and postoperative PFF remains greater with uncemented stems compared to either of these cemented stem subtypes. PFF continues to be a devastating complication following primary THA and is associated with high complication and mortality rates. Recent efforts have focused on identifying implant-related risk factors for PFF in order to guide preventative strategies, and therefore the purpose of this article is to present the current evidence on the effect of cemented femoral stem design on the risk of PFF.

Major complications after total hip arthroplasty with the direct anterior approach at a high-volume Ontario tertiary care centre.

The rate of major surgical complications for high-volume orthopedic surgeons using the direct anterior approach (DAA) in Ontario, Canada, is not known. The purpose of this study was to investigate the rate of major surgical complications after total hip arthroplasty (THA) using DAA performed by experienced orthopedic surgeons at a high-volume tertiary care centre in Ontario. We conducted a retrospective cohort review of primary THA through DAA performed by 2 experienced fellowship-trained surgeons at an academic hospital in London, Ontario, between Jan. 1, 2012, and May 1, 2019. We excluded the first 100 cases to allow for surgeon learning curves. We recorded major surgical complications (intraoperative events, postoperative periprosthetic fractures, dislocation requiring closed or open reduction, implant failure [aseptic loosening or subsidence], early (< 6 wk) deep wound infection requiring irrigation and débridement, late (≥ 6 wk) deep wound infection requiring irrigation and débridement, and wound complications [wound dehiscence, stitch abscess, erythema, hematoma or seroma]) within 1 year of THA. A total of 875 primary DAA THA procedures were included. The rates of surgical complications were 0.9% for intraoperative events, 1.5% for postoperative periprosthetic fractures, 0.8% for implant failure, 0.7% for early deep wound infection, 0.1% for late deep wound infection and 3.2% for wound complications; there were no cases of dislocation. The rate of revision for implant failure within 1 year was 0.1%. Male sex was associated with a greater risk of implant failure (p = 0.01), and having a higher body mass index was associated with both increased rates of infection (p < 0.01) and having a wound complication (p < 0.01). Intraoperative events, postoperative periprosthetic fractures, implant failure, deep wound infection and wound complications accounted for the major surgical complications within 1 year of THA through DAA. The low revision rate suggests that DAA is a safe approach for THA.

Construction and evaluation of a nomogram prediction model for periprosthetic fractures after total hip arthroplasty

To construct and evaluate nomogram prediction model for periprosthetic fractures in patients undergoing total hip arthroplasty (THA). A total of 538 patients who underwent THA from April 2013 to February 2019 were selected as the research subjects, including 318 males and 220 females, aged 40 to 60 years old with an average age of (50.79±6.37) years old. All patients with THA were divided into non-fracture group (506 patients) and fracture group (32 pathents) according to the 3-year follow-up results. Univariate and multivariate Logistic regression analyses were performed to analyze the influencing factors of postoperative periprosthetic fractures in patients with THA. A nomogram prediction model for periprosthetic fractures in patients undergoing THA was constructed, and the validity and discrimination of the prediction model were evaluated. The proportion of patients with osteoporosis, trauma history, and hip revision in the fracture group were higher than those in the non-fracture group(P<0.05), and the proportion of bone cement prosthesis was lower than that in the non-fracture group(P<0.05). The osteoporosis status[OR=4.177, 95%CI(1.815, 9.617), P<0.05], trauma history[OR=7.481, 95%CI(3.104, 18.031), P<0.05], and hip revision[OR=11.371, 95%CI(3.220, 40.153, P<0.05] were independent risk factors for postoperative periprosthetic fractures in patients undergoing THA, cemented prosthesis [OR=0.067, 95%CI(0.019, 0.236), P<0.05] was an independent protective factor for postoperative periprosthetic fractures in patients undergoing THA(P<0.05). Hosmer-Lemeshow goodness of fit test showed that χ2=7.864, P=0.325;the area under the curve (AUC) for periprosthetic fractures in patients undergoing THA was 0.892 with a sensitivity of 87.5% and a specificity of 77.7% by receiver operating characteristic(ROC) curve. The nomogram prediction model for periprosthetic fractures after THA constructed in this study has good discrimination, which is beneficial to clinical prediction of periprosthetic fractures in patients undergoing THA, and facilitates individualized fracture prevention.

Radiologic, clinical, and patient-reported outcomes in stemless reverse shoulder arthroplasty at a mean of 46 months

BackgroundThe humeral stem can be a cause of problems in shoulder arthroplasty, for example loss of bone stock, intraoperative and postoperative periprosthetic fractures or postoperative infections involving the medullary canal. Therefore, stemless reverse shoulder arthroplasty (slRSA) has gained popularity, particularly in terms of preserving bone stock. However, there is limited data available on the mid-term outcomes of slRSA. The objective of this study was to evaluate the clinical, radiological, and patient-reported outcomes of slRSA at a minimum follow-up period of two years. MethodsData on all stemless reverse shoulder prostheses implanted between January 2016 and October 2020 were collected. Patients were followed up at 6 weeks, 6 months, 12 months, and 24 months postoperatively. Clinical and radiological data as well as patient-reported outcomes measures (PROM) were assessed with validated questionnaires (UCLA, ASES, Quick-Dash, VAS pain, Subjective Shoulder Value (SSV), Constant-Murley Score (CS)). All patients had a minimum follow-up of 2 years. ResultsDuring the observation period, 26 shoulders in 25 patients fulfilled the inclusion criteria. The mean follow-up was 46.8 (range 25 -66) months. The mean age was 70.1 years (range 59.9 – 86.4 years). At most recent follow-up, a significant improvement was noted in the ASES score (55.9±19.9 vs. 85.6±10.7, p<0.001), SSV (44.3±18.7 vs. 85.3±10.4, p<0.001), Quick-Dash-Score (40.6±22.0 vs. 17.8±13.9, p<0.001), VAS pain score (4.6±3.2 vs. 0.9±1.2, p<0.001) and ROM in flexion (66±53 vs. 154±22, p<0.001) as well as in the absolute (44.1±18.7 vs. 83.1±10.1, p<0.001) and relative CS (62.1±27.8 vs. 111.9±13.3, p<0.001). Scapular notching was observed in 16% of cases, and radiolucent lines were detected in 28% of cases without symptoms of implant loosening. No revision was necessitated by any causes related to the stemless humeral component. ConclusionsWith an ASES score showing a 30-point improvement and thus exceeding the MCID of 21 points and no revisions due to the stemless component, these results indicate that slRSA is a viable option, providing good to excellent mid-term outcomes that are comparable to those of stemmed reverse shoulder prostheses, with the added advantage of bone stock preservation.

Register data on cemented arthroplasty : Aproof for cementless fixation?

Hip and knee implants can be either fixated without cement, press-fit, or with bone cement. Real-world data from arthroplasty registers, as well as studies, provide abroad database for the discussion of cemented versus uncemented arthroplasty procedures. What is the recommendation for cemented or cementless anchorage of hip and knee implants based on the current evidence from international arthroplasty registries and meta-analyses? Arecommendation is generated by means of adirect comparison of data from the arthroplasty registries of eight different countries (USA, Germany, Australia, UK, Sweden, Norway, New Zealand, and The Netherlands), the comparison of 22review studies and meta-analyses based on registry data, as well as the evaluation of the recommendation of healthcare systems of different nations. For this purpose, reviews and meta-analyses whose results were statistically significant were selected, as were the annual reports of the arthroplasty registries that were current at the time of writing. For knee endoprostheses, along survival time, as well as alower risk of revision can be achieved with the help of cemented anchorage with antibiotic-laden bone cement. In patients aged 70years and older, cemented anchorage of the hip stem implant significantly reduces the risk of intraoperative or postoperative periprosthetic fracture (times four), this applies both to elective total hip arthroplasties (TEPs) and to hemiarthroplasty after femoral neck fractures. Antibiotic-loaded bone cement significantly (p = 0.041) reduces the risk of periprosthetic infection, especially in patients with femoral neck fractures. Total knee replacement with antibiotic-loaded bone cement is well established in Germany and evidence based. Registry data and meta-analyses recommend cemented fixation of the hip stem in older patients-in Germany the evidence-based recommendations must still be transferred to daily practice.

Postoperative Medial Malleolar Fractures in Total Ankle Replacement are Associated with Medial Malleolar Width and Coronal Alignment

Category: Ankle Arthritis; Ankle Introduction/Purpose: There is limited evidence regarding risk factors for medial malleolar fractures after total ankle arthroplasty (TAA). A previous study showed that patients with medial pain following TAA had significantly thinner (&lt;11mm) medial malleolar width, which has been used as a threshold for placing a prophylactic screw. However, this study included only six patients with pain over the medial malleolus. Other previously reported risk factors include coronal malalignment and poor bone quality. Therefore, this study examined the risk factors of postoperative medial malleolar stress fractures. In addition, we sought to assess the effect of the prophylactic screw placement. We hypothesized that a medial malleolar width &lt;11mm and varus malalignment would be associated with increased fracture risk and that the prophylactic screw placement would be protective. Methods: A case-control study was conducted on 838 patients undergoing primary TAA between 2015 and. TAA revisions, arthrodesis takedowns, and intraoperative medial malleolar fractures were excluded. Demographic and surgical data were obtained. A total of 21 patients with postoperative medial malleolar stress fractures &gt; 4 weeks postoperatively (cases) were identified through radiologic assessment (radiograph, CT, or MRI) and matched to a control group of 129 patients. Radiographic evaluation included pre- and post-TAA tibial coronal alignment, postoperative medial malleolar width at the tibial component, and prophylactic screw fixation. Demographics and radiographic variables were compared between cohorts using the Mann-Whitney U test for continuous variables and Pearson Chi-square for categorical variables. Logistic regression was used to investigate the association of medial malleolar stress fractures with gender, coronal tibial implant size, postoperative coronal alignment, prophylactic screw fixation, and medial malleolar width using odds ratios (OR), and standard error (SE). Results: Of 838 TAAs, 2.51% sustained a postoperative medial malleolar fracture (n = 21). Of these, 13/21 (61.9%) required reoperation: internal fixation (12) and TAA revision (1). Mean (SD) medial malleolar width was significantly smaller in the fracture cohort (8.62 mm [1.63]) than in controls (11.78mm [1.75]), P&lt;0.001). Mean (SD) postoperative tibial component coronal alignment was 92.2º (2.82) for patients with medial malleolar fracture and 90.23º (1.68) for the control cohort (P = 0.003). Postoperative varus tibial component alignment (OR = 1.61 [95%CI 1.16 02 − 2.22], P = 0.004) and smaller medial malleolar width (OR = 0.11 [95% CI 0.04 02 − 0.3], P &lt; 0.001) were associated with increased probability of a post-TAA medial malleolar fracture. Prophylactic screw fixation resulted in a 90% reduction in the odds of a fracture (OR = 0.10 [95%CI 0.02 02 − 0.64], P = 0.015). A medial malleolar width of 10.31 mm was identified as a threshold for predicting a medial malleolar stress fracture. Conclusion: In this study, the prevalence of postoperative periprosthetic fractures after TAA was similar to prior studies. Decreased medial malleolar thickness and postoperative varus malalignment were associated with an increased risk of a postoperative medial malleolar stress fracture. A malleolar width of 10.31 mm was identified as a potential threshold. Prophylactic medial malleolar screw fixation was protective and associated with a 90% reduction in fracture probability. Surgeons should consider prophylactic screw fixation patients with a medial malleolar width &lt; 10.31 mm or at risk of postoperative varus deformity.