Postoperative Periprosthetic Femoral Fractures Research Articles

Low rate of early periprosthetic fractures in cementless short-stem total hip arthroplasty using a minimally invasive anterolateral approach

PurposeMinimally invasive (MIS) approaches in combination with short stems have gained popularity in recent years in total hip arthroplasty (THA). A decreased risk for periprosthetic femoral fractures (PFFs) is reported for cementless short-stem THA, but in contrast to other approaches, the risk factors for PFFs for short-stem THA using MIS anterolateral approach in supine position are not described in literature.MethodsA single-center consecutive series of 1052 hips in 982 patients, performed between 2014 and 2019 with a short curved stem and a press fit using an MIS anterolateral approach in supine position, was retrospectively screened for inclusion. Fourteen patients were lost to follow-up. Therefore, 1038 THAs in 968 patients were included. Risk factors for intra- and postoperative PFFs within 90 days were analyzed. We investigated for sex, age, body mass index (BMI), diagnosis, and laterality.ResultsIn total, 18 PFFs (1.7%) occurred. Intraoperative fracture occurred in ten cases ( 0.9%), with another eight cases (0.8%) occurring postoperatively. Increased American Society of Anesthesiologists (ASA) Score was a significant risk factor for PFF (p = 0.026), whereas sex (p = 0.155), age (p = 0.161), BMI (p = 0.996), and laterality (p = 1.000) were not. Seven PFFs (0.7%) required revision arthroplasty.ConclusionCementless short-stem THA using the MIS anterolateral approach is a procedure with a low number of PFFs within 90 days from index surgery. Fracture rates are comparable to other MIS approaches, and comparable femoral short stems are used. Age, sex, and BMI were not identified as risk factors of PFF, while risk for PFF increased with ASA Score.Level of EvidenceLevel IV

Midterm Results of Primary Exeter Cemented Stem in a Select Patient Population.

Most North American surgeons predominantly use uncemented stems in primary total hip arthroplasties (THAs) and reserve cemented stems for selected older patients and those with poor bone quality. However, data on this "selective use" strategy for cemented stems in the population at risk for periprosthetic fracture and implant loosening are limited. The purpose of this study was to describe implant survivorship, complications, and radiographic results of a specific collarless, polished, tapered cemented stem (Exeter; Stryker) used selectively in a predominantly elderly population undergoing primary THA. We identified 386 patients who underwent a total of 423 primary THAs with selectively utilized Exeter stems for the treatment of osteoarthritis between 2006 and 2017. In the same time period, 11,010 primary THAs were performed with uncemented stems and 961 with non-Exeter cemented stems. The mean patient age was 77 years, 71% were female, and the mean body mass index was 29 kg/m2. Competing risk analysis accounting for death was utilized to determine cumulative incidences of revision and reoperation. The mean follow-up was 5 years (range, 2 to 12 years). The 10-year cumulative incidence of any femoral component revision in this patient cohort was 4%, with 10 stems revised at the time of the latest follow-up. There were no intraoperative femoral fractures. The indications for revision were postoperative periprosthetic femoral fracture (n = 6), dislocation (n = 3), and infection (n = 1). There were no revisions for femoral loosening. The 10-year cumulative incidence of reoperation was 10%. The 10-year cumulative incidence of Vancouver B periprosthetic femoral fracture was 2%. Radiographically, there were no cases of aseptic loosening or osteolysis. There was a significant improvement in median Harris hip score, from 53 preoperatively to 92 at a mean follow-up of 5 years (p < 0.001). The strategy of selectively utilizing a collarless, polished, tapered cemented stem produced a low (4%) cumulative incidence of stem revision at 10 years postoperatively and resulted in no cases of aseptic loosening. The use of the Exeter stem did not eliminate postoperative femoral fractures in this predominantly elderly, female patient population. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The influence of femoral component design on postoperative periprosthetic femoral fracture after uncemented direct anterior total hip arthroplasty in the elderly

IntroductionAging populations and expanding indications will greatly increase the volume of total hip arthroplasty (THA) in all age groups, including patients over 70 years old. Minimally invasive, uncemented direct anterior THA offers potential advantages for treating elderly patients. However, literature indicates higher risks of postoperative periprosthetic femur fractures (PPFFs) with both direct anterior THA and uncemented femoral stems. This retrospective study investigates the influence of femoral stem design on PPFF incidence in uncemented direct anterior THA among patients older than 70 years. Methods557 primary THAs in patients aged 70 or over were reviewed for PPFFs from a consecutive series of 2011 patients undergoing direct anterior THA from a fellowship-trained adult reconstruction surgeon from 2015 to 2020. Exclusion criteria included age (<70) and posterior approach. For the first cohort of 361 patients (79 of which passed exclusion criteria) the surgeon used a single-tapered, proximally porous coated, collarless titanium stem. For the next 1650, (478 of which passed exclusion), the surgeon used a dual-tapered, collared, hydroxyapatite-coated titanium stem. Included patients were carefully monitored until March 2021 for PPFFs. A Fisher's exact test was used to compare the incidence PPFFs between the 2 implant designs. Results2 of 79 (2.5%) patients had atraumatic PPFFs at an average of 19.5 days post-operatively in the first cohort. Both experienced a Vancouver type B2 periprosthetic fracture and required femoral revision. No patients (0/478, 0%) in the second group sustained a PPFF. (P = 0.0199). ConclusionIn this comparison, the dual-taper, hydroxyapatite-coated implant had a significantly lower PPFF rate among elderly patients than a single-taper, proximally porous stem without a collar.

Uncemented femoral stem design might have an impact on postoperative periprosthetic femur fracture pattern. A Comparison between flat-wedge and dual-wedge stems

IntroductionType I, flat-wedge and type II, dual-wedge stems are currently two common stem types used in primary, uncemented hip arthroplasty. The prevalence of periprosthetic femur fracture is higher in type I stems, possibly because of the different shapes and areas of bone contact. We aimed to compare the fracture pattern, stem stability during the fracture and type of subsequent procedures in periprosthetic femur fractures between type I and II stems. Materials and MethodsThis was a retrospective, cross-sectional study conducted in a single tertiary referral hospital of Taipei, Taiwan. We included primary hip arthroplasty procedures using type I or type II stems complicated with postoperative periprosthetic femur fractures. We recorded the age, sex, ASA grade, index procedure, institution of where the index procedure was performed, trauma mechanism, time from index procedure to fracture, procedure for periprosthetic fracture and radiographic parameters including Dorr type, Vancouver classification, stem stability, fracture pattern, type and brand of the stems for analysis. ResultsWe included 132 patients who had undergone surgery for periprosthetic femur fracture for type I (N = 46) or type II (N = 86) stems. The mean age was 74.5 years and 52.3% of the patients were female. Type I stems were associated with a higher proportion of a complex fracture pattern (52.2% vs. 8.2%), femoral stem loosening (78.2% vs. 60.4%) and a higher rate of revision stem procedures (69.6% vs. 50.0%) compared with type II stems. Using multivariate analysis, type I stem was the only factor for a complex fracture pattern in the overall population (aOR: 23.60, 95% CI: 6.54–85.16), hemiarthroplasty (aOR: 160.50, 95% CI: 9.77–2635.95) and total hip arthroplasty (aOR: 14.17, 95% CI: 2.92–68.79) subgroups. ConclusionWe observed a difference in fracture patterns between type I and type II stems. Type I stems appear to be an independent risk factor for a complex fracture pattern in patients who had undergone primary hip arthroplasty.

Postoperative periprosthetic femoral fracture around total hip replacements: current concepts and clinical outcomes.

The rising incidence of postoperative periprosthetic femoral fracture (PFF) presents a significant clinical and economic burden.A detailed understanding of risk factors is required in order to guide preventative strategies.Different femoral stems have unique characteristics and management strategies must be tailored appropriately.Consensus regarding treatment of PFFs around well-fixed stems is lacking, but revision surgery may provide more predictable outcomes for unstable fracture patterns and fractures around polished taper-slip stems.Future research should focus on implant-related risk factors, treatment of concurrent metabolic bone disease and the use of large endoprostheses.Cite this article: EFORT Open Rev 2020;5:558-567. DOI: 10.1302/2058-5241.5.200003

Feasibility of the Inner-Side-Out Use of the LC-DCP for Periprosthetic Femoral Fracture in Total Hip Arthroplasty.

The optimal technique for plate fixation to treat type B and C periprosthetic femoral fractures (PFFs) is unclear. The purpose of this study is to evaluate the radiographic results of inner-side-out limited contact dynamic compression plate (LC-DCP) to treat PFFs during or after total hip arthroplasty (THA). This retrospective study comprised of four men and six women with an average age of 64.7years who underwent open reduction and internal fixation with an inner-side-out LC-DCP technique to treat PFFs; the reduction was maintained preliminary with the use of contoured plate and cables, and the grooves on the undersurface of LC-DCP for limited contact was used to hold and prevent the cables from slippage during tightening the cables. There were five intraoperative and five postoperative PFFs after THA. According to the Vancouver classification, the intraoperative PFFs included type B2 in two, B3 in one and C3 in two patients while postoperative PFFs were categorized into type B1 in one, type B2 in two and type C in two patients. The mean follow-up duration was 5.9years (range 1-10.4). We evaluated radiographic union and complications after index operation. All patients demonstrated radiographic bone union at an average follow-up duration of 4.4months (range 3-8). Two patients showed stem subsidence after revision THA and one patient demonstrated a subsequent peri-implant fracture around the distal end of plate after union of the initial PPF; one patient underwent re-revision THA for stem loosening while another patient went through refixation for the peri-implant fracture. There was no nonunion, infection, nerve injury, or dislocation. The inner-side-out LC-DCP technique showed satisfactory radiographic outcome. In certain situations where locking plates are not available, this technique might be a useful alternative for treating type B and C PFFs.

Introduction of a New Treatment Algorithm Reduces the Number of Periprosthetic Femoral Fractures After Primary Total Hip Arthroplasty in Elderly Females

BackgroundIncreasing global usage of cementless prostheses in total hip arthroplasty (THA) presents a challenge, especially for elderly patients. To reduce the risk of early periprosthetic femoral fractures (PFFs), a new treatment algorithm for females older than 60 years undergoing primary THA was introduced. The aim of this study was to determine the impact of the new treatment algorithm on the early risk of perioperative and postoperative PFFs and guideline compliance. MethodsA total of 2405 consecutive THAs that underwent primary unilateral THA at our institution were retrospectively identified in the period January 1, 2013-December 31, 2018. A new treatment algorithm was introduced on April 1, 2017 with female patients aged older than 60 years intended to receive cemented femoral components. Before this, all patients were scheduled to receive cementless femoral components. Demographic data, number of perioperative and postoperative PFFs, and surgical compliance were recorded, analyzed, and intergroup differences compared. ResultsThe utilization of cemented components in female patients older than 60 years increased from 12.3% (n = 102) to 82.5% (n = 264). In females older than 60 years, a significant reduction in the risk in early postoperative and intraoperative PFF after introduction of the new treatment algorithm was seen (4.57% vs 1.25%; P = .007 and 2.29% vs 0.31%; P = .02, respectively). Overall risk for postoperative and intraoperative fractures combined was also reduced in the entire cohort (4.1% vs 2.0%; P = .01). ConclusionUse of cemented fixation of the femoral component in female patients older than 60 years significantly reduces the number of PFFs. Our findings support use of cemented femoral fixation in elderly female patients.

Risk Factors for Revision of Polished Taper-Slip Cemented Stems for Periprosthetic Femoral Fracture After Primary Total Hip Replacement: A Registry-Based Cohort Study from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man.

Total hip replacement (THR) with a cemented polished taper-slip (PTS) femoral stem has excellent long-term results but is associated with a higher postoperative periprosthetic femoral fracture (PFF) risk compared with composite beam stems. This study aimed to identify risk factors associated with PFF revision following THR with PTS stems. In a retrospective cohort study, 299,019 primary THRs using PTS stems from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) were included, with a median follow-up of 5.2 years (interquartile range [IQR], 3.1 to 8.2 years). The adjusted hazard ratio (HR) of PFF revision was estimated for each variable using multivariable Cox survival regression analysis. Of 299,019 THR cases, 1,055 underwent revision for PFF at a median time of 3.1 years (IQR, 1.0 to 6.1 years). The mean age (and standard deviation) was 72 ± 9.7 years, 64.3% (192,365 patients) were female, and 82.6% (247,126 patients) had an American Society of Anesthesiologists (ASA) class of 1 or 2. Variables associated with increased PFF were increasing age (HR, 1.02 per year), intraoperative fracture (HR, 2.57 [95% confidence interval (CI), 1.42 to 4.66]), ovaloid (HR, 1.96 [95% CI, 1.22 to 3.16]) and round cross-sectional shapes (HR, 9.58 [95% CI, 2.29 to 40.12]), increasing stem offset (HR, 1.07 per millimeter), increasing head size (HR, 1.04 per millimeter), THR performed from 2012 to 2016 (HR, 1.45 [95% CI, 1.18 to 1.78]), cobalt-chromium stem material (HR, 6.7 [95% CI, 3.0 to 15.4]), and cobalt-chromium stems with low-viscosity cement (HR, 22.88 [95% CI, 9.90 to 52.85]). Variables associated with a decreased risk of PFF revision were female sex (HR, 0.52 [95% CI, 0.45 to 0.59]), increasing stem length (HR, 0.97 per millimeter), and a ceramic-on-polyethylene bearing (HR, 0.55 [95% CI, 0.36 to 0.85]). Increased risk of PFF revision was associated with PTS stems that are short, have high offset, are used with large femoral heads, are made of cobalt-chromium, or have ovaloid or round cross-sectional shapes. Large increases in PFF risk were associated with cobalt-chromium stems used with low-viscosity cement. Further study is required to confirm causation. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Operation rate is more than double the revision rate for periprosthetic femur fractures.

Periprosthetic femur fractures (PFFs) following hip arthroplasty can lead to significant morbidity due to their impact on mobility and the need for surgery. Its incidence often measured by the prosthesis revision rate reported in joint replacement registries. However, many PFFs are also treated with prosthesis retention and internal fixation. Minimally displaced and stable fractures may be treated without surgery. Knowledge of the difference between the number of femoral revisions for PFF (well reported in registries) and the number of surgeries for PFF overall would allow us to estimate the overall surgical burden. This study aims to determine the number of post-operative PFF in three hospitals and compare those treated with revision surgery to those PFF treated with internal fixation and femoral stem retention. By determining this difference, we can ascertain a more accurate estimate of the overall surgical burden of PFF. Patients 50 years and older who sustained a post-operative PFF between 1 January 2011 and 31 December 2017 at three public hospitals were extracted from hospital records. The number of revision procedures was compared to the number of re-operations of any type. There were 200 patients admitted for management of PFF. One hundred and forty-three (71.5%) required an operation of which 67 (47%) were revision arthroplasty. The overall surgical burden of PFF is approximately twice that represented by the revision rate.

Prevalence of Postoperative Periprosthetic Femur Fractures Between Two Different Femoral Component Designs Used in Direct Anterior Total Hip Arthroplasty

BackgroundPeriprosthetic femur fractures are a well-documented complication following direct anterior uncemented total hip arthroplasty. The purpose of this study is to compare the prevalence of postoperative periprosthetic femur fractures between 2 different femoral component designs used in direct anterior total hip arthroplasty. MethodsBeginning in February 2015, a single fellowship-trained adult reconstruction surgeon performed 361 consecutive direct anterior total hip replacements using a flat, single-taper, wedged femoral implant. In June 2016, that same surgeon, using the exact same surgical technique and postoperative weight-bearing protocol, began using a dual-taper, hydroxyapatite-coated implant for 789 consecutive hips. The patients were carefully monitored for 3 months after surgery to identify the frequency of periprosthetic femur fractures. A Fisher’s exact test was used to determine if the prevalence of periprosthetic femur fractures differed between the 2 implant designs. ResultsFive of 361 (1.4%) patients sustained proximal femur fractures at an average of 19.6 days postoperatively in the first group, all demonstrating a Vancouver type B2 periprosthetic fracture and requiring femoral revision. No patients (0/789, 0%) in the second cohort sustained a postoperative, periprosthetic fracture (P = .006). ConclusionIn this comparison of 2 consecutive cohorts, the dual-taper, hydroxyapatite-coated implant had a statistically significant lower postoperative periprosthetic fracture rate than a flat, single-taper, wedged design.

Mortality After Periprosthetic Femur Fractures During and After Primary and Revision Total Hip Arthroplasty.

We determined mortality rates after intraoperative and postoperative periprosthetic femur fractures in primary and revision total hip arthroplasty (THA). The study population comprised 522 intraoperative and 480 postoperative femur fractures in 26,250 primary THA patients and 590 intraoperative and 224 postoperative femur fractures in 4,532 revision THA patients. The risk of death was examined using Cox regression models. In primary THA, intraoperative periprosthetic femur fractures were not associated with excess risk of death (hazard ratio, 1.03; 95% confidence interval, 0.86 to 1.22). The risk of death was slightly elevated among primary THA patients with postoperative femur fractures (hazard ratio, 1.19; 95% confidence interval, 1.08 to 1.43), but the excess risk was only confined to patients with comorbid orthopaedic conditions. In revision THA, neither intraoperative nor postoperative periprosthetic femur fractures were associated with excess risk of death. Periprosthetic femur fractures are not associated with excess mortality among primary osteoarthritis patients. Level III.

Cumulative Long-Term Incidence of Postoperative Periprosthetic Femoral Fractures Using an Uncemented Tapered Titanium Hip Stem: 26- to 32-Year Results

BackgroundAlthough falling is becoming a major problem in the elderly, little is known about the long-term incidence of postoperative periprosthetic femoral fractures (PFF) after total hip arthroplasty (THA) using uncemented stems with a minimum follow-up of 26 years postoperatively. MethodsIn a consecutive series, the cumulative incidence of PFF after uncemented THA using a straight, collarless, tapered titanium stem was retrospectively reviewed in 354 hips (326 patients). After a mean follow-up of 28 (26-32) years postoperatively, 179 hips had died and 5 hips had been lost to follow-up. Kaplan-Meier survival analysis was used to estimate cumulative percentage probability of PFF. ResultsAt final follow-up, a total of 27 fractures in 27 patients had occurred. In 15 hips, the stem had to be revised, and in 10 the fracture was treated by open reduction and internal fixation. Two patients declined further surgery. The cumulative percentage probability of PFF was 1.6% (95% confidence interval, 0.7 to 3.8) at 10 years and 13.2% (95% confidence interval, 8.5 to 20.2) at 29 years after primary THA. There was no association between the occurrence of fracture and gender, age at primary THA, cup revision, or canal fill index. ConclusionOur findings indicate that PFF is the major mode of failure in the long term after uncemented THA using a tapered titanium stem. More research is needed to evaluate the reasons and risk factors for PFF after THA, thus providing better prophylaxis for those at risk and to compare the long-term incidence using different fixation methods and implants. Level of evidenceIV.

Reduced Incidence of Intraoperative Femur Fracture With a Second-Generation Tapered Wedge Stem

BackgroundIntraoperative fractures during total hip arthroplasty (THA) are more common when using cementless stems. The purpose of this study was to investigate the impact of a new shorter second-generation cementless, tapered wedge stem with improved proximal femoral fit in reducing the incidence of intraoperative fracture. MethodsA retrospective study was conducted on primary THA cases performed at a single institution using a first-generation or second-generation cementless stem from 2006-2016. All intraoperative femur fractures were identified, as well as early 30-day postoperative periprosthetic femur fractures, which could represent nondisplaced intraoperative fractures that were initially missed. Risk for intraoperative femur fracture was analyzed using logistic regression, accounting for demographic covariates and surgeon. ResultsOf 6473 primary THA performed with a cementless, tapered wedge stem during the study period, 3126 used a first-generation stem and 3347 used a second-generation stem. The incidence of intraoperative fracture was 1.79% for first-generation stems and 0.24% for second-generation stems, representing a 7.5-fold reduction of risk for fracture. After accounting for covariates, the odds of intraoperative fracture were 0.33 using the second-generation stem relative to the first-generation stem (P = .01). However, there was no significant difference in the odds of early 30-day postoperative fractures using the second-generation stem (odds ratio 0.93, P = .56). ConclusionA new second-generation cementless stem resulted in a 7.5-fold decrease in the incidence of intraoperative femur fracture compared with the preceding stem.

Increased risk of intraoperative and early postoperative periprosthetic femoral fracture with uncemented stems

Background and purpose — The use of uncemented fixation in total hip arthroplasty (THA) is increasing. Registry studies have indicated an increased risk of revision of uncemented implants due to early periprosthetic femoral fracture. In this paper, we describe the incidence and predisposing factors for intraoperative and early postoperative (≤ 90 days) periprosthetic femoral fractures after cemented and uncemented THA.Patients and methods — This was a prospective observational study in 8 Danish high-volume centers from February 2010 to November 2013. We used the 90-day follow-up from the Danish National Patient Registry and patient records. We obtained intraoperative information from the Danish Hip Arthroplasty Registry and from surgical notes.Results — Of 7,169 primary consecutive THAs, 5,482 (77%) were performed using uncemented femoral components. The total incidence of periprosthetic femoral fractures ≤ 90 days postoperatively was 2.1% (n = 150). 70 fractures were detected intraoperatively (46 required osteosynthesis). 51 postoperatively detected fractures occurred without trauma (42 of which were reoperated) and 29 were postoperative fall-related fractures (27 of which were reoperated). 134 fractures (2.4%) were found in uncemented femoral components and 16 (0.9%) were found in cemented femoral components (p < 0.001). Uncemented femoral stem (relative risk (RR) = 4.1, 95% CI: 2.3–7.2), medically treated osteoporosis (RR =2.8, CI: 1.6–4.8), female sex (RR =1.6, CI: 1.1–2.2), and age (RR =1.4 per 10 years, CI: 1.2–1.6) were associated with increased risk of periprosthetic femoral fracture when analyzed using multivariable regression analysis.Interpretation — Uncemented femoral components were associated with an increased risk of early periprosthetic femoral fractures, especially in elderly, female, and osteoporotic patients.

Periprosthetic femoral fractures and trying to avoid them: what is the contribution of femoral component design to the increased risk of periprosthetic femoral fracture?

Periprosthetic femoral fractures (PFF) following total hip arthroplasty (THA) are devastating complications that are associated with functional limitations and increased overall mortality. Although cementless implants have been associated with an increased risk of PFF, the precise contribution of implant geometry and design on the risk of both intra-operative and post-operative PFF remains poorly investigated. A systematic review was performed to aggregate all of the PFF literature with specific attention to the femoral implant used. A systematic search strategy of several journal databases and recent proceedings from the American Academy of Orthopaedic Surgeons was performed. Clinical articles were included for analysis if sufficient implant description was provided. All articles were reviewed by two reviewers. A review of fundamental investigations of implant load-to-failure was performed, with the intent of identifying similar conclusions from the clinical and fundamental literature. In total 596 articles were initially identified, with 34 being eligible for analysis. Aggregate analysis of 1691 PFFs in 342 719 primary THAs revealed a significantly higher number of PFFs with cementless femoral implants (p < 0.001). Single-wedge and double-wedge (fit-and-fill) femoral implants were associated with a threefold increase in PFF rates (p < 0.001) compared with anatomical, fully coated and tapered/rounded stems. Within cemented stems, loaded-taper (Exeter) stems were associated with more PFFs than composite-beam (Charnley) stems (p = 0.004). Review of the fundamental literature revealed very few studies comparing cementless component designs. Very few studies within the PFF literature provide detailed implant information. Cementless implants, specifically those of single-wedge and double-wedge, have the highest PFF rates in the literature, with most investigations recommending against their use in older patients with osteoporotic bone. This review illustrates the need for registries and future PFF studies to record implant name and information for future analysis. Furthermore, future biomechanical investigations comparing modern implants are needed to clarify the precise contribution of implant design to PFF risk. Cite this article: Bone Joint J 2017;99-B(1 Supple A):50-9.

Substantially higher prevalence of postoperative periprosthetic fractures in octogenarians with hip fractures operated with a cemented, polished tapered stem rather than an anatomic stem: A prospective cohort study involving 979 hips

Background and purpose - Recent studies have demonstrated a high incidence of postoperative periprosthetic femoral fracture (PPF) in elderly patients treated with 2 commonly used cemented, polished ...

Clinical characteristics and risk factors of periprosthetic femoral fractures associated with hip arthroplasty

Periprosthetic femoral fracture (PFF) is a complicated complication of both primary and revision hip arthroplasty with an increasing incidence. The present study aimed to summarize the clinical characteristics and identify the risk factors for PFF which would be potentially helpful in the prevention and treatment of PFF.We retrospectively analyzed the clinical data of 89 cases of PFF, and a case–control study was designed to identify the potential risk for intraoperative and postoperative PFF in both primary and revision hip arthroplasty.The overall incidence of PFF was 2.08% (intraoperative: 1.77%, postoperative: 0.30%, revision: 13.60%, and primary: 0.97%). The most commonly used treatment strategy was fixation with cerclage wire or band for intraoperative PFF, whereas long stem revision with plate or cortical allograft strut fixation was the main treatment strategy for postoperative PFF. The risk factors for intraoperative PFF in primary total hip arthroplasty (THA) included the diagnosis of development dysplasia of the hip (DDH) (odds ratio [OR] = 5.01, 95%CI, 1.218–20.563, P=0.03) and CBR ≥ 0.49 (OR = 3.34, 95%CI, 1.138–9.784, P = 0.03). The increased age was associated with increased incidence of postoperative PFF in primary THA (OR = 1.09, 95%CI, 1.001–1.194, P = 0.04). As for the intraoperative PFF in revision THA, we found that receiving multiple operations before revision (OR = 2.45, 95%CI, 1.06–5.66, P = 0.04), revisions due to prosthetic joint infection (OR = 6.72, 95%CI, 1.007–44.832, P = 0.04), the presence of cementless implant before revision (OR = 13.54, 95%CI, 3.103–59.08, P = 0.001), and femoral deformity (OR = 8.03, 95%CI, 1.656–38.966, P = 0.01) were all risk factors.Screening for high-risk patients, preoperative templating, and detailed discharge instructions may be the potential strategies to reduce the incidence of PFF. The treatment of PFFs should take into account Vancouver classification system, patient's characteristics as well as the experience of the operating surgeon.

Substantially higher prevalence of postoperative peri­prosthetic fractures in octogenarians with hip fractures operated with a cemented, polished tapered stem rather than an anatomic stem

Background and purpose — Recent studies have demonstrated a high incidence of postoperative periprosthetic femoral fracture (PPF) in elderly patients treated with 2 commonly used cemented, polished tapered stems. We compared the prevalence and incidence rate of PPF in a consecutive cohort of octagenerians with femoral neck fractures (FNFs) treated with either a collarless, polished tapered (CPT) stem or an anatomic matte stem (Lubinus SP2).Patients and methods — In a multicenter, prospective cohort study, we included 979 hips in patients aged 80 years and above (72% females, median age 86 (80–102) years) with a femoral neck fracture as indication for surgery. 69% of the patients were classified as ASA class 3 or 4. Hip-related complications and repeat surgery were assessed at a median follow-up of 20 (0–24) months postoperatively.Results — 22 hips (2.2%) sustained a PPF at a median of 7 (0–22) months postoperatively; 14 (64%) were Vancouver B2 fractures. 7 of the 22 surgically treated fractures required revision surgery, mainly due to deep infection. The cumulative incidence of PPFs was 3.8% in the CPT group, as compared with 0.2% in the SP2 group (p < 0.001). The risk ratio (RR) was 16 (95% CI: 2–120) using the SP2 group as denominator.Interpretation — The CPT stem was associated with a higher risk of PPF than the SP2 stem. We suggest that the tapered CPT stem should not be used for the treatment of femoral neck fractures in patients over 80 years.

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.

Cemented versus Uncemented Hemiarthroplasty for Displaced Femoral Neck Fractures: 5-year Followup of a Randomized Trial

Displaced femoral neck fractures usually are treated with hemiarthroplasty. However, the degree to which the design of the implant used (cemented or uncemented) affects the outcome is not known and may be therapeutically important. In this randomized controlled trial, we sought to compare cemented with cementless fixation in bipolar hemiarthroplasties at 5 years in terms of (1) Harris hip scores; (2) femoral fractures; (3) overall health outcomes using the Barthel Index and EQ-5D scores; and (4) complications, reoperations, and mortality since our earlier report on this cohort at 1-year followup. We present followup at a median of 5 years after surgery (range, 56-65 months) from a randomized trial comparing a cemented hemiarthroplasty (112 hips) with an uncemented, hydroxyapatite-coated hemiarthroplasty (108 hips), both with a bipolar head. Results were previously reported at 1-year followup. Harris hip scores, Barthel Index, and EQ-5D scores were assessed by one research nurse and one orthopaedic surgeon. Complications and reoperations were determined by chart review and radiographs examined by three orthopaedic surgeons. Sixty patients (56%) had died in the cemented group and 63 (60%) in the uncemented group. Respectively, three and two patients (2.7% and 1.9%) were completely lost to followup. Harris hip scores at 5 years were higher in the uncemented group than in the cemented group (86.2 versus 76.3; mean difference 9.9; 95% confidence interval [CI], 1.9-17.9). The prevalence of postoperative periprosthetic femoral fractures was 7.4% in the uncemented group and 0.9% in the cemented group (hazard ratio [HR], 9.3; 95% CI, 1.16-74.5). Barthel Index and EQ-5D scores were not different between the groups. Between 1 and 5 years, we found no additional infections or dislocations. The mortality rate was not different between the groups (HR, 1.2; 95% CI, 0.82-1.7). Both arthroplasties may be used with good medium-term results after displaced femoral neck fractures. The uncemented hemiarthroplasty may result in higher hip scores but appears to carry an unacceptably high risk of later femoral fractures. Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.