Risk Of Femoral Fracture Research Articles

Cortical Thickness Index and Canal Calcar Ratio: A Comparison of Proximal Femoral Fractures and Non-Fractured Femora in Octogenarians to Centenarians.

Background: The cortical thickness index (CTI) is a measure of bone quality and it correlates with the risk of proximal femoral fractures. The purpose of this study was to investigate the CTI in femoral neck, trochanteric fractures and non-fractured femora in geriatric patients and to determine whether there is a correlation between the CTI and the presence of a fracture. Methods: One hundred and fifty patients (fifty femoral neck- (FNFx), fifty trochanteric fractures (TFx) and fifty non-fractured (NFx)) with a mean age of 91 (range 80-104) years were included. Hip radiographs (antero-posterior (ap), lateral) were evaluated retrospectively. Measurements on the proximal femoral inner and outer cortices, including CTI and Dorr's canal calcar ratio (CCR), were assessed for inter-observer reliability (ICC), differences of each fracture and correlation of parameters. Results: The mean ap CTI on the affected side was 0.43, 0.45 and 0.55 for FNFx, TFx and NFx, respectively. There was a significant difference of the ap CTI and CCR comparing the injured and healthy side for both fracture cohorts (p < 0.001). Patients with FNFx or TFx had significantly lower CTI on both sides compared to the NFx group (p < 0.05). There was no difference for CTI (p = 0.527) or CCR (p = 0.291) when comparing both sides in the NFx group. The mean inter-observer reliability was good to excellent (ICC 0.88). Conclusions: In proximal femoral fractures, the CTI and CCR are reduced compared with those in non-fractured femora. Both parameters are reliable and show a good correlation in geriatric patients. Therefore, especially for geriatric patients, the CTI and CCR may help to predict fracture risk and consult patients in daily practice.

Femoral Component Design Is Associated With the Risk of Periprosthetic Femur Fracture After Cementless THA in Patients 65 Years or Older.

Periprosthetic femur fracture is a known complication after THA. The associated risk of cementless femoral component design for periprosthetic femur fracture in a registry population of patients older than 65 years has yet to be clearly identified. (1) Is femoral stem geometry associated with the risk of periprosthetic femur fracture after cementless THA? (2) Is the presence or absence of a collar on cementless femoral implant designs associated with the risk of periprosthetic femur fracture after THA? We analyzed American Joint Replacement Registry data from 2012 to March 2020. Unique to this registry is the high use of cementless femoral stems in patients 65 years and older. We identified 266,040 primary cementless THAs during the study period in patients with a diagnosis of osteoarthritis and surgeries linked to supplemental Centers for Medicare and Medicaid data where available. Patient demographics, procedure dates, and reoperation for periprosthetic femur fracture with revision or open reduction and internal fixation were recorded. The main analysis was performed comparing the Kheir and Chen classification: 42% (112,231 of 266,040) were single-wedge, 22% (57,758 of 266,040) were double-wedge, and 24% (62,983 of 266,040) were gradual taper/metadiaphyseal-filling cementless femoral components, which yielded a total of 232,972 primary cementless THAs. An additional analysis compared cementless stems with collars (20% [47,376 of 232,972]) with those with collarless designs (80% [185,596 of 232,972]). A Cox proportional hazard regression analysis with the competing risk of death was used to evaluate the association of design and fracture risk while adjusting for potential confounders. After controlling for the potentially confounding variables of age, sex, geographic region, osteoporosis or osteopenia diagnosis, hospital volume, and the competing risk of death, we found that compared with gradual taper/metadiaphyseal-filling stems, single-wedge designs were associated with a greater risk of periprosthetic femur fracture (HR 2.9 [95% confidence interval (CI) 2.2 to 3.9]; p < 0. 001). Compared with gradual taper/metadiaphyseal-filling stems, double-wedge designs showed an increased risk of periprosthetic femur fracture (HR 3.0 [95% CI 2.2 to 4.0]; p < 0. 001). Collarless stems showed an increased risk of periprosthetic fracture compared with collared stems (HR 7.8 [95% CI 4.1 to 15]; p < 0. 001). If cementless femoral fixation is used for THA in patients 65 years or older, surgeons should consider using gradual taper/metadiaphyseal-filling and collared stem designs because they are associated with a lower risk of periprosthetic femur fracture. Future investigations should compare gradual taper/metadiaphyseal-filling and collared cementless designs with cemented fixation in this population. Level III, therapeutic study.

Differences in bone histomorphometry between White postmenopausal women with and without atypical femoral fracture after long-term bisphosphonate therapy.

Bone histomorphometric endpoints in transilial biopsies may be associated with an increased risk of atypical femoral fracture (AFF) in patients with osteoporosis who take antiresorptives, including bisphosphonates (BPs). One way to test this hypothesis is to evaluate bone histomorphometric endpoints in age-, gender-, and treatment time-matched patients who either had AFF or did not have AFF. In this study, we performed transiliac bone biopsies in 52 White postmenopausal women with (n= 20) and without (n= 32) AFFs, all of whom had been treated for osteoporosis continuously with alendronate for 4-17yr. Despite the matched range of treatment duration (4-17yr), AFF patients received alendronate for significantly longer time (10.7yr) than non-AFF patients (8.0yr) (P= .014). Bone histomorphometric endpoints reflecting microstructure and turnover were assessed in cancellous, intracortical, and endocortical envelopes from transilial biopsy specimens obtained from BP-treated patients 3-6mo after AFF and from non-AFF patients with similar age-, gender-, and range of BP treatment duration. However, in both cancellous and intracortical envelopes, AFF patients had significantly lower wall thickness (W.Th) and higher osteoclast surface (Oc.S/BS) than non-AFF patients. In addition, AFF patients had significantly higher eroded surface (ES/BS) only in the intracortical envelope. None of the dynamic variables related to bone formation and turnover differed significantly between the groups. In conclusion, in the ilium of BP-treated patients with osteoporosis, AFF patients have lower thickness of superficial bone (lower W.Th) of the cancellous and cortical envelopes than non-AFF patients. AFF and non-AFF patients have a similar bone turnover rate in the ilium. Furthermore, in this population, as in previous work, AFF is more likely to occur in BP-treated patients with longer treatment duration.

Hip &amp; Pelvis

The February 2024 Hip &amp; 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?

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.

Interimplant femoral fracture: analysis of risk factors.

Interimplant fractures present a significant challenge for orthopedic surgeons. Despite a noticeable rise in these cases in recent years, our understanding of this specific fracture type remains limited. This study aims to analyze and identify the primary risk factors associated with interimplant femoral fractures. We conducted a retrospective analysis involving 20 patients with interimplant femoral fracture (case group) and 18 patients who had both proximal and distal femoral implants but did not experience interimplant fractures (control group). Our analysis focused on demographic factors (age, sex, BMI) and radiographic parameters (implant types, gap between implants, cortical thickness, femoral canal area) to identify potential risk factors. In the case group, all patients were females, whereas in the control group, 16 patients were female and 2 were males. The mean age in the case group was 88 [Formula: see text] 9years and in the control group was 87 [Formula: see text] 12years. None of the demographic differences reached statistical significance. The mean cortical thickness in the case group was 6 [Formula: see text] 2.25mm, whereas in the control group, it was 9 [Formula: see text] 1.75mm (p-value < 0.001). The median gap between the proximal and distal tips of the implants measured 194 [Formula: see text] 126mm in the case group and 66 [Formula: see text] 78mm in the control group (p-value < 0.001). Additionally, the mean femoral canal area was 284 [Formula: see text] 102 mm2 in the case group and 227 [Formula: see text] 26 mm2 in the control group (p-value < 0.010). Our data indicate that a small cortical thickness, a wide femoral canal area, and having a hip arthroplasty despite a gap between the implants exceeding 110mm are factors that elevate the risk of interimplant femoral fracture. Notably, osteoporosis therapy emerges as a protective factor against these fractures.

Bisphosphonate Use and Risk of Atypical Femoral Fractures: A Danish Case-Cohort Study With Blinded Radiographic Review.

Prolonged bisphosphonate (BP) treatment for osteoporosis prevents hip and other fractures but causes atypical femoral fractures (AFF). To establish the relationship between patterns of BP use and the risk of AFF and hip fractures. Other potential risk factors for AFF were also examined. This population-based case-cohort study utilized data from the Danish National Healthcare system, including longitudinal records of medication use, healthcare utilization, and x-ray images. Among all 1.9 million Danish adults ≥50, those with subtrochanteric or femoral shaft fractures between 2010 and 2015 (n = 4973) were identified and compared to a random sample (n = 37 021). Bisphosphonate use was collected from 1995-2015. Fracture radiographs (n = 4769) were reviewed by blinded study radiologists to identify AFFs (n = 189) using established criteria. Traditional hip fractures in the random sample (n = 691) were identified by ICD-10. Compared to <1 year of BP use, 5 to 7 years of use was associated with a 7-fold increase in AFF (adjusted HR = 7.29 [CI: 3.07, 17.30]); the risk of AFF fell quickly after discontinuation. The 5-year number needed to harm for one AFF was 1424, while the 5-year number needed to treat to prevent one hip fracture was 56. Glucocorticoid and proton pump inhibitor use were independently associated with increased AFF risk. Thirty-one percent of those with AFF had no BP exposure. The risk of AFF increases with duration of BP use but the beneficial effects of BP therapy in adults ≥50 dramatically exceed this increased risk. Nearly one-third of those with AFF have no BP exposure.

Association between Central Nervous System Drugs and Femoral Fracture Risk in Japanese Individuals ≥80 Years Old: A Case-crossover Study.

Objectives To assess the association between concomitant use of central nervous system drugs and femoral fracture risk in individuals ≥80 years old in Japan. Methods A case-crossover design was used, defining the case period as 3 days before the fracture diagnosis and the control period as 31-33, 34-36, and 37-39 days prior. The association between the daily intake of central nervous system drugs (Anatomical Therapeutic Chemical codes) and fracture risk was analyzed using conditional logistic regression. Patients Using the Japanese administrative claims database, we examined elderly patients diagnosed with femoral neck fractures between January 1, 2009, and December 31, 2020. Results In 255,875 patients, the concomitant use of central nervous system drugs increased the odds ratios of femoral fracture (3.41[95% confidence interval: 3.27-3.55], 3.69 [3.46-3.91], 3.76 [3.42-4.13], and 4.34 [3.86-4.86] for an intake of >0-1, >1-2, >2-3, and >3 central nervous system drugs, respectively). Conclusions The concomitant use of central nervous system drugs is associated with an increased risk of femoral fractures in individuals ≥80 years old in Japan.

Design and In Vitro Validation of an Orthopaedic Drill Guide for Femoral Stem Revision in Total Hip Arthroplasty.

Cemented total hip arthroplasty (THA) demonstrates superior survival rates compared to uncemented procedures. Nevertheless, most younger patients opt for uncemented THA, as removing well-fixed bone cement in the femur during revisions is complex, particularly the distal cement plug. This removal procedure often increases the risk of femoral fracture or perforation, haemorrhage and weakening bone due to poor drill control and positioning. Aim of this study was to design a novel drill guide to improve drill positioning. A novel orthopaedic drill guide was developed, featuring a compliant centralizer activated by a drill guide actuator. Bone models were prepared to assess centralizing performance. Three conditions were tested: drilling without guidance, guided drilling with centralizer activation held, and guided drilling with centralizer activation released. Deviations from the bone centre were measured at the entry and exit point of the drill. In the centralizing performance test, the drill guide significantly reduced drill hole deviations in both entry and exit points compared to the control ([Formula: see text]). The absolute deviation on the exit side of the cement plug was 10.59mm (SD 1.56) for the 'No drill guide' condition, 3.02mm (SD 2.09) for 'Drill guide - hold' and 2.12mm (SD 1.71) for 'Drill guide - release'. The compliant drill guide centralizer significantly lowered the risk of cortical bone perforation during intramedullary canal drilling in the bone models due to better control of the cement drill position. Clinical and Translational Impact Statement: The drill guide potentially reduces perioperative risks in cemented femoral stem revision. Future research should identify optimal scenarios for its application.

Regional CT value in prediction of proximal femoral fracture

To investigate CT values of cancellous bone in femoral neck in adults over 60 years with proximal femoral fractures. From January 2020 to December 2020, a retrospective analysis was performed on 280 subjects aged 60 years or older who underwent bilateral hip CT examination, including 85 males and 195 females, 120 on the left side and 160 on the right side, aged 75 (66, 82) years old. One hundred thirty-six patients with proximal femoral fractures were included in study group and 144 patients without fractures were included in control group. GEOptima CT was used to scan and reconstruct horizontal, coronal and sagittal layers of proximal femur. CT values of cancellous bone in femoral neck were measured and compared between two groups. The relationship between CT values of cancellous bone of femoral neck and proximal femoral fracture was analyzed statistically. In terms of age, fracture group aged 79(73.3, 85.0) years old, non-fracture group aged 69.5 (64.0, 78.8) years old, and had significant difference in age between two groups (P<0.05). In terms of CT value, regional CT value in fracture group was 8.62(-3.62, 27.15) HU, which was lower than that in non-fracture group 34.31(-5.93, 71.74) HU(P<0.05). CT value on coronal view in fracture group was -8.48(-30.96, 17.46) HU, which was lower than that in non-fracture group 40.49(5.55, 80.71) HU (P<0.05). CT value on sagittal view in fracture group was -31.28(-54.91, -5.11) HU, which was lower than that in non-fracture group 7.74(-20.12, 44.54) HU (P<0.05). CT values on horizontal view in fracture group was 0.17(-23.13, 24.60) HU, which was lower than that in non-fracture group 46.40(10.42, 85.18) HU(P<0.05). The mean regional CT values among three planes in the fracture group were lower than those in the non-fracture group. Logistic regression analysis showed coronal CT value was influencing factors of proximal femoral fracture, and it could be written into regression equations that predict probability of fracture. In adults aged over 60 years old, CT values of cancellous bone of femoral neck decreased with increasing age. The smaller CT value of cancellous bone of femoral neck, the greater risk of proximal femoral fracture.

Impact of Long-Term Swimming Exercise on Rat Femur Bone Quality.

Considering the conflicting evidence regarding the potential long-term detrimental effect of swimming during growth on femur quality and fracture risk, our aim was to investigate the effect of eight months of swimming on femur quality. Twenty male eight-week-old Wistar rats were assigned into a swimming (SW; n = 10; 2 h/day, 5 days/week) or active control group (CG; n = 10, housed with running wheel) for eight months. Plasma osteocalcin and C-terminal telopeptide of type I collagen concentrations (ELISA) were assessed at baseline, four, and eight months of protocol. Femur structure (micro-computed tomography), biomechanical properties (three-point bending), and cellular density (histology) were determined after the protocol. SW displayed a lower uncoupling index, suggesting higher bone resorption, lower empty lacunae density, cortical and trabecular femur mass, femur length and cortical thickness, and higher cortical porosity than CG (p < 0.05). Although both biomarkers' concentrations decreased in both groups throughout the experiment (p < 0.001), there were no significant differences between groups (p > 0.05). No differences were also found regarding biomechanical properties, bone marrow adiposity, and osteocyte and osteoclast densities (p > 0.05). Long-term swimming was associated with unbalanced bone turnover and compromised femur growth, lower femur mass, and deteriorated cortical bone microarchitecture. However, femur trabecular microarchitecture and biomechanical properties were not affected by swimming.

Towards understanding how bisphosphonate-dependent alterations to nutrient canal integrity can contribute to risk for atypical femoral fractures: Biomechanical considerations and potential relationship to a real-world analogy.

Bisphosphonates are a class of drugs which have shown good efficacy in the treatment of post-menopausal osteoporosis, as well as a good safety profile. However, side-effects such as risk for atypical femoral fractures (AFF) have appeared, leading to a decline in use of the drugs by many patients who would benefit from the treatment. While patient characteristics have contributed to improved understanding of risk factors, the mechanisms involved that explain AFF risk have not appeared. Recently, the possibility that the mechanism(s) involved drug-induced modification of cells of the nutrient canals of the femur and subsequent compromise in the bone matrix has been published. The present Hypothesis article builds on the concept presented earlier and expands into biomechanical considerations. An analogy of the mechanisms involved to a real-life scenario is also presented. While this analogy has limitations, consideration of the biomechanical implications of progressive alterations to defects presented by compromised nutrient canal-bone matrix also presents potential relationships with AFF risk.

Antiresorptive Drugs and the Risk of Femoral Shaft Fracture in Men and Women With Osteoporosis: A Cohort Study Using the National Database of Health Insurance Claims of Japan.

This cohort study aimed to estimate incidence rates of femoral shaft fracture in patients who were treated with antiresorptive drugs. We used data from the National Database of Health Insurance Claims of Japan from April 2009 and October 2016. All patients with new use of an antiresorptive drug, prescription-free period of ≥3 months, and no prior femoral fractures were included. Femoral shaft fractures were identified using a validated definition based on International Classification of Diseases, 10th revision (ICD-10) codes. Incidence rate ratios were estimated using Poisson regression, with adjustment for sex, age, and the Charlson Comorbidity Index. We identified 7,958,655 patients (women: 88.4%; age ≥75 years: 51.2%). Femoral shaft fractures were identified in 22,604 patients. Incidence rates per 100,000 person-years were 74.8 for women, 30.1 for men, 30.1 for patients aged ≤64 years, 47.7 for patients aged 65-74 years, and 99.0 for patients aged ≥75 years. Adjusted incidence rate ratios in patients taking versus not taking each type of antiresorptive drug were 1.00 (95% confidence interval [CI], 0.98-1.03) for bisphosphonates, 0.46 (95% CI, 0.44-0.48) for selective estrogen receptor modulators, 0.24 (95% CI, 0.18-0.32) for estrogens, 0.75 (95% CI, 0.71-0.79) for calcitonins, and 0.93 (95% CI, 0.84-1.03) for denosumab. The adjusted incidence rate ratio for alendronate was 1.18 (95% CI, 1.14-1.22). The incidence rates of femoral shaft fracture varied across patients treated with different antiresorptive drugs. Further research on a specific antiresorptive drug can increase understanding of the risk of femoral shaft fracture.

Deep-Learning Automation of Preoperative Radiographic Parameters Associated With Early Periprosthetic Femur Fracture After Total Hip Arthroplasty

BackgroundThe radiographic assessment of bone morphology impacts implant selection and fixation type in total hip arthroplasty (THA) and is important to minimize the risk of periprosthetic femur fracture (PFF). We utilized a deep-learning algorithm to automate femoral radiographic parameters and determined which automated parameters were associated with early PFF. MethodsRadiographs from a publicly available database and from patients undergoing primary cementless THA at a high-volume institution (2016 to 2020) were obtained. A U-Net algorithm was trained to segment femoral landmarks for bone morphology parameter automation. Automated parameters were compared against that of a fellowship-trained surgeon and compared in an independent cohort of 100 patients who underwent THA (50 with early PFF and 50 controls matched by femoral component, age, sex, body mass index, and surgical approach). ResultsOn the independent cohort, the algorithm generated 1,710 unique measurements for 95 images (5% lesser trochanter identification failure) in 22 minutes. Medullary canal width, femoral cortex width, canal flare index, morphological cortical index, canal bone ratio, and canal calcar ratio had good-to-excellent correlation with surgeon measurements (Pearson’s correlation coefficient: 0.76 to 0.96). Canal calcar ratios (0.43 ± 0.08 versus 0.40 ± 0.07) and canal bone ratios (0.39 ± 0.06 versus 0.36 ± 0.06) were higher (P < .05) in the PFF cohort when comparing the automated parameters. ConclusionsDeep-learning automated parameters demonstrated differences in patients who had and did not have early PFF after cementless primary THA. This algorithm has the potential to complement and improve patient-specific PFF risk-prediction tools.

Relationship between menopausal hormone therapy and incidence of fractures in postmenopausal women

Objective Long-term protective effects of menopausal hormone therapy (MHT) at fractures with different doses and components are controversial. We analyzed the effect of MHT on the incidence of spine and femur fractures according to MHT type, age at commencement, duration and dose of hormones in Korean women. Method This retrospective study evaluated propensity score-matched patients with MHT from the Korean National Health Insurance Service database. Among women aged ≥50 years with menopause between 2004 and 2007, spine and femur fracture incidence until 2017 was analyzed in 36,446 women who had received MHT for >1 year. Estrogen–progesterone therapy (EPT), estrogen-only therapy (ET) or tibolone therapy was conducted. Results EPT significantly lowered the incidence of spine and femur fractures with a conventional dose, but not with a low dose. Tibolone significantly decreased the incidence of spine fractures in women aged 50–59 years when used for >5 years, and the incidence of femur fractures in women older than 60 years when used for >3 years. ET significantly lowered the risk of femur fractures when estradiol was used for >5 years. Conclusion In menopausal women, all MHT including conventional-dose EPT, ET and tibolone tended to lower the incidence of fractures. The effects, however, varied with the type of fracture and type of MHT.

Low Risk of Fracture Using a Cementless Triple-Tapered Collared Femoral Stem With Automated Impaction in Direct Anterior Approach Total Hip Arthroplasty

BackgroundDirect anterior approach (DAA) total hip arthroplasty (THA) has been associated with increased periprosthetic femoral fracture (PFF) risk. The aim of our study was to evaluate the fracture risk utilizing a triple-tapered, collared stem with automated impaction through the anterior approach. MethodsWe retrospectively reviewed consecutive DAA THA procedures at a single institution performed by 4 experienced DAA THA surgeons between 2019 and 2021. We collected data on age, sex, body mass index, preoperative diagnosis, and intraoperative and early postoperative PFF within 6 weeks postoperatively. Preoperative radiographs were evaluated to determine femoral neck-shaft angle and Dorr classification. We used Wilcoxon rank sum or Chi-square tests to assess differences between patients who did and did not have PFF. We also evaluated potential risk factors for PFF in unadjusted and adjusted regression analyses. In all, 24 PFFs (1.6%) occurred. There were 18 fractures (1.2%) recognized and managed intraoperatively (15 calcar, 2 greater trochanter, 1 posterior cortical). There were 6 PFFs (0.4%) identified postoperatively (5 greater trochanter, 1 diaphyseal), of which one required revision surgery. ResultsIdentified risk factors for fracture in adjusted regression models included women (odds ratio [OR] = 2.76, P = .047), preoperative coxa valga (OR = 4.54, P = .005), and coxa vara (OR = 2.85, P = .03). ConclusionsThe incidence of PFFs is low using a triple-tapered, collared cementless femoral stem with automated impaction through the DAA. Our findings agree with previous reports that have demonstrated women and preoperative valgus neck angle are risk factors for PFF.

Femur Fractures in 5 Individuals With Pantothenate Kinase-associated Neurodegeneration: The Role of Dystonia and Suggested Management.

Pantothenate kinase-associated neurodegeneration (PKAN) is a rare, neurodegenerative disorder that manifests with progressive loss of ambulation and refractory dystonia, especially in the early-onset classic form. This leads to osteopenia and stress on long bones, which pose an increased risk of atraumatic femur fractures. The purpose of this study is to describe the unique challenges in managing femur fractures in PKAN and the effect of disease manifestations on surgical outcomes. A retrospective case review was conducted on 5 patients (ages 10 to 20y) with PKAN with a femur fracture requiring surgical intervention. Data regarding initial presentation, surgical treatment, complications, and outcomes were obtained. All patients were non-ambulatory, with 4 of 5 patients sustaining an atraumatic femur fracture in the setting of dystonia episode. One patient had an additional contralateral acetabular fracture. Postoperatively, 4 of the 5 patients sustained orthopaedic complications requiring surgical revision, with 3 of these secondary to dystonia. Overall, 4 required prolonged hospitalization in the setting of refractory dystonia. Femur fractures in PKAN present distinct challenges for successful outcomes. A rigid intramedullary rod with proximal and distal interlocking screws is most protective against surgical complications associated with refractory dystonia occurring during the postoperative period. Multidisciplinary planning for postoperative care is essential and may include aggressive sedation and pain management to decrease the risk of subsequent injuries or complications. Level IV.

How Much Protection Does a Collar Provide? Assessing Risk of Early Periprosthetic Femur Fractures Following Total Hip Arthroplasty in Elderly Patients

BackgroundPeriprosthetic fractures (PPFs) account for approximately 25% of early revisions following total hip arthroplasty (THA). Cemented femoral fixation is associated with a lower-risk of PPF, and collared-cementless stems may reduce the risk as well. The objective of this study was to compare early-PPF rates between cemented, collared-cementless, and non-collared cementless stems in elderly patients. MethodsA consecutieve-series of 11,522 primary THAs performed between 2016 and 2021 at our institution in patients >65 years of age was identified. Stem types used were categorized as cemented, collared-cementless, or non-collared cementless. Patients undergoing THA who had cemented-stems were older, more commonly women, and more likely to have a posterior-approach. To reduce confounding of patient characteristics, we matched patients in the 3 stem-categories according to age, sex, and body mass index. This generated 3-groups (cemented, collared-cementless, and non-collared cementless) consisting of 936 patients per group. The mean age of these 2,808 patients was 73 years, the mean body mass index was 27, and 67% were women. Logistic regressions were used to evaluate risk-factors for early-PPF. In the entire cohort of primary THA in elderly patients, there were 85 early PPFs (0.7%) over the study period. ResultsNon-collared cementless stems were associated with an increased risk of early PPF (OR: 3.11; P = .03) compared to collared-cementless stems. There were no early PPFs in the matched cemented cohort, 6 early PPFs in the matched collared-cementless cohort, and 16 early-PPFs in the matched non-collared cementless cohort (0% versus 0.64% versus 1.71%, P < .001). ConclusionsIn this large-series of patients >65 years of age undergoing primary THA, cemented stem fixation had the lowest incidence of early PPF, but collared-cementless stems had a nearly 3-fold decrease in risk for early PPF compared to non-collared cementless stems.

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.

Proximal hip fractures in 71,920 elderly patients: incidence, epidemiology, mortality and costs from a retrospective observational study

BackgroundThe risk of proximal femoral fractures increases with aging, causing significant morbidity, disability, mortality and socioeconomic pressure. The aims of the present work are (1) to investigate the epidemiology and incidence of these fractures among the elderly in the Region of Lombardy; (2) to identify the factors influencing survival; (3) to identify the factors influencing hospitalization and post-operative costs.MethodsThe Region of Lombardy provided anonymized datasets on hospitalized patients with a femoral neck fracture between 2011 and 2016, and anonymized datasets on extra-hospital treatments to track the patient history between 2008 and 2019. Statistical evaluations included descriptive statistics, survival analysis, Cox regression and multiple linear models.Results71,920 older adults suffered a femoral fracture in Lombardy between 2011 and 2016. 76.3% of patients were females and the median age was 84. The raw incidence of fractures was stable from year 2011 to year 2016, while the age-adjusted incidence diminished. Pertrochanteric fractures were more spread than transcervical fractures. In patients treated with surgery, receiving treatment within 48 h reduced the hazard of death within the next 24 months. Combined surgical procedures led to increased hazard in comparison with arthroplasty alone, while no differences were observed between different arthroplasties and reduction or fixation. In patients treated conservatively, age and male gender were associated with higher hazard of death. All patients considered, the type of surgery was the main factor determining primary hospitalization costs. A higher number of surgeries performed by the index hospital in the previous year was associated with financial savings. The early intervention significantly correlated with minor costs.ConclusionsThe number of proximal femoral fractures is increasing even if the age-adjusted incidence is decreasing. This is possibly due to prevention policies focused on the oldest cohort of the population. Two policies proved to be significantly beneficial in clinical and financial terms: the centralization of patients in high-volume hospitals and a time limit of 48 h from fracture to surgery.Trial registrationNon applicable.