Risk Of Femoral Fracture Research Articles

SAT232 Patients With Chronic Hypoparathyroidism Have Higher Risk Of Vertebral Fracture And Lower Risk Of Femoral Fracture Compared To Controls

Abstract Disclosure: S. Bjornsdottir: None. W. Kamal: None. B.L. Langdahl: None. T. Spelman: None. B.L. Clarke: None. O. Kampe: None. Context: Previous studies have shown that patients with hypoparathyroidism (hypoPT) have reduced bone remodeling, with consequent increases in bone density, and abnormalities in microarchitecture and bone strength. It is still not clear whether there is an increased risk of fractures in patients with hypoPT. Objective: The aim of this study was to evaluate the risk of fractures in patients with hypoPT in Sweden. Patients: The Swedish National Patient Register, the Swedish Prescribed Drug Register and the Total Population Register were used to identify 1982 patients with chronic hypoPT (duration ≥ 12 months), and 19820 controls matched by age, sex and county of residency between 1997-2018. The 10th revision of the International Classification of Diseases (ICD) was used to identify fractures. Results: Patients with hypoPT did not have higher risk of any fracture compared to controls (HR 0.96; 95% CI 0.86-1.08). However, patients with hypoPT had a slightly higher risk of vertebral fractures (HR 1.33; 95% CI 1.01-1.75), p= 0.047 and a lower risk of femoral fractures (HR 0.60; 95% CI 0.45-0.82), p= 0.001. There was no significant difference in the risk of fractures of the forearm, p= 0.177, proximal humerus, p= 0.096 or pelvis, p= 0.446. There was no difference in the risk of any fracture between females and males with hypoPT (p for interaction= 0.511). Patients with surgical hypoPT had a significantly higher risk of any fracture compared with patients with non-surgical hypoPT (p for interaction= 0.006). Conclusion: The risk of any fracture was not increased in patients with hypoPT. However, the risk of vertebral fracture was increased, and the risk of femoral fracture was lower than for matched controls. No difference was found in fracture risk between females and males. Patients with surgical hypoPT had a higher fracture risk compared to patients with non-surgical hypoPT. Presentation: Saturday, June 17, 2023

Improved femoral micro-architecture in adult male individuals with overweight: fracture resistance due to regional specificities.

It is still unclear whether femoral fracture risk is positively or negatively altered in individuals with overweight. Considering the lack of studies including men with overweight, this study aimed to analyze regional specificities in mechano-structural femoral properties (femoral neck and intertrochanteric region) in adult male cadavers with overweight compared to their normal-weight age-matched counterparts. Ex-vivo osteodensitometry, micro-computed tomography, and Vickers micro-indentation testing were performed on femoral samples taken from 30 adult male cadavers, divided into the group with overweight (BMI between 25 and 30 kg/m2; n = 14; age:55 ± 16 years) and control group (BMI between 18.5 and 25 kg/m2; n = 16; age:51 ± 18 years). Better quality of trabecular and cortical microstructure in the inferomedial (higher trabecular bone volume fraction, trabecular thickness, and cortical thickness, coupled with reduced cortical pore diameter, p < 0.05) and superolateral femoral neck (higher trabecular number and tendency to lower cortical porosity, p = 0.043, p = 0.053, respectively) was noted in men with overweight compared to controls. Additionally, the intertrochanteric region of men with overweight had more numerous and denser trabeculae, coupled with a thicker and less porous cortex (p < 0.05). Still, substantial overweight-induced change in femoral osteodensitometry parameters and Vickers micro-hardness was not demonstrated in assessed femoral subregions (p > 0.05). Despite the absence of significant changes in femoral osteodensitometry, individuals with overweight had better trabecular and cortical femoral micro-architecture implying higher femoral fracture resistance. However, the microhardness was not significantly favorable in the individuals who were overweight, indicating the necessity for further research.

OA07 A case of severe osteoporosis treated with teriparatide following the development of bilateral atypical femoral fractures due to IV zoledronic acid

Abstract Introduction Atypical femoral fractures (AFF) are a rare complication of long-term anti-resorptive therapy. A literature review of 310 cases of AFF did reveal a median duration of bisphosphonate therapy of 7 years. Additionally, simultaneous glucocorticoid use was seen in 34% of the cases and was reported to have a 5-fold increase in one case series. Around 70% of patients do describe a prodrome of thigh pain and around quarter of all cases will have bilateral involvement. Case description A 59-year-old lady with a background diagnosis of Behçet’s disease was referred for continuation of osteoporosis care. History of Fractures 2003- left-sided distal radial fracture; 2017 - refractured again after a fall; left 5th metatarsal fracture a few months later. 2019 - right navicular fracture, left pubic rami fracture and left iliac wing fracture, after a fall from the bus In 2023, she has tripped and fell from the standing height resulting in a left femoral shaft fracture, which had radiological features of an atypical femoral fracture. She denied any prodromal thigh pain. The orthopaedic team did an intramedullary nailing to the left femoral shaft. X-ray of the right femur shaft revealed cortical thickening of right mid femoral shaft. Treatment History In 2009, she was started on oral bisphosphonate therapy and from 2020 to 2022 received 3 doses of IV zoledronic acid at the national Behçet’s centre in Birmingham. She has been on long-term steroid therapy due to the underlying Behçet's disease and was on prednisolone 7mg daily when she was referred to us. Management of AFF The orthopaedic team initially recommended a watch and wait policy for the right side; however, following discussions with the patient and with us, prophylactic nailing of the right femoral shaft was done 2 months later. Investigations DXA scan in 2022: spine T-score of−3.3 (L2 −3.6, L3 −3.9, L4 −3.7); femoral neck T-score of −2.5. Despite treatment with oral and then parenteral bisphosphonates for the last 12 years, there is a significant reduction in BMD with 18.2% decrease in the spine and 7.1% decrease in the femoral neck compared to the last DEXA in 2019. Management plan The next step was to treat her with teriparatide, which she is currently having without any problems. We shall continue it for 24 months. Discussion Atypical femoral fractures are rare. Anti-resorptive medication including bisphosphonates and denosumab are known to cause atypical femoral fractures. Teriparatide, being anabolic agent, is not associated with the increased risk of atypical femoral fractures. While there are no randomised controlled studies about the use of teriparatide in healing atypical femoral fractures, there are some case reports where teriparatide had shown improved fracture healing in AFF. After the 24 months, to ‘lock in the effects’ of teriparatide, an anti-resorptive medication will be required. Because both femoral shafts have received intramedullary nailing, we would consider IV zoledronic acid after the 24 months of teriparatide. This is the approach supported by the European Calcified Tissue Society in their systemic review and recommendations on ‘Medical Management of Patients After Atypical Femur Fractures’ (https://doi.org/10.1210/clinem/dgz295). Key learning points Consider atypical femoral fracture in patients who are on anti-resorptive therapy and complain of thigh/groin pain. Atypical femoral fractures can be bilateral; therefore, evaluate both sides. Teriparatide can be used to treat osteoporosis in patients with atypical femoral fracture, but considerations will have to be made in relation to subsequent therapy.

396 Systematic Review and Meta-Analysis of Studies Comparing the Rate of Post Operative Periprosthetic Fracture Following Hip Arthroplasty with a Polished Taper Slip Versus Composite Beam Stem

Abstract Aim To compare the incidence of post-operative periprosthetic femoral fractures (POPFF) following hip replacement with either a cemented polished taper stem (PTS) or cemented composite beam stem (CB) in comparative studies. Method A systematic review of comparative studies, written in English, and published in peer-reviewed journals since year 2000 to 2021 was conducted using Ovid MEDLINE, EMBASE, Web of Science, and Scopus. Methodology followed the Preferred Reporting items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Study quality was assessed using the Newcastle-Ottawa scale. Cohorts were classified as high or low risk of POPFF based on patient risk factors. Metanalysis was performed using a random effects model and relative incidence with 95% confidence intervals were reported. Results The overall study quality was good. 913,021 patients from 18 cohorts were included in the meta-analysis. 294,540 patients received a CB stem and 618,481 received a PTS stem. For patients at low risk of POPFF the incidence rate ratio (IRR) was 3.14 (CI: 2.48, 3.98) for the PTS group versus CB group. For patients at high risk of POPFF the IRR of 9.87 (CI: 3.63, 26.80) for the PTS group versus the CB group. Conclusions The risk of POPFF is lower when hip arthroplasty was performed using a composite beam stem versus a polished taper slip stem. This protective effect was greatest in patients with a higher risk of POPFF. Surgeons should consider the effect of cemented stem choice on risk of subsequent periprosthetic femur fracture, particularly in frail or elderly patients at risk of periprosthetic femoral fracture.

Holistic pedestrian safety assessment for average males and females.

An integrated assessment framework that enables holistic safety evaluations addressing vulnerable road users (VRU) is introduced and applied in the current study. The developed method enables consideration of both active and passive safety measures and distributions of real-world crash scenario parameters. The likelihood of a specific virtual testing scenario occurring in real life has been derived from accident databases scaled to European level. Based on pre-crash simulations, it is determined how likely it is that scenarios could be avoided by a specific Autonomous Emergency Braking (AEB) system. For the unavoidable cases, probabilities for specific collision scenarios are determined, and the injury risk for these is determined, subsequently, from in-crash simulations with the VIVA+ Human Body Models combined with the created metamodel for an average male and female model. The integrated assessment framework was applied for the holistic assessment of car-related pedestrian protection using a generic car model to assess the safety benefits of a generic AEB system combined with current passive safety structures. In total, 61,914 virtual testing scenarios have been derived from the different car-pedestrian cases based on real-world crash scenario parameters. Considering the occurrence probability of the virtual testing scenarios, by implementing an AEB, a total crash risk reduction of 81.70% was achieved based on pre-crash simulations. It was shown that 50 in-crash simulations per load case are sufficient to create a metamodel for injury prediction. For the in-crash simulations with the generic vehicle, it was also shown that the injury risk can be reduced by implementing an AEB, as compared to the baseline scenarios. Moreover, as seen in the unavoidable cases, the injury risk for the average male and female is the same for brain injuries and femoral shaft fractures. The average male has a higher risk of skull fractures and fractures of more than three ribs compared to the average female. The average female has a higher risk of proximal femoral fractures than the average male. A novel methodology was developed which allows for movement away from the exclusive use of standard-load case assessments, thus helping to bridge the gap between active and passive safety evaluations.

Fracture pattern and risk factors for reoperation after treatment of 156 periprosthetic fractures around an anatomic cemented hip stem.

The Lubinus SP2 stem has been associated with a very low risk of periprosthetic femoral fractures (PPFFs). We aimed, primarily, to study the radiographic morphology of PPFFs close to a Lubinus SP2 stem. Secondarily, we analyzed whether higher reoperation rate was correlated to the revision method chosen or to the characteristics of the fracture and of the bone. The study included 156 femoral fractures close to a Lubinus cemented stem. These fractures were treated in 40 hospitals in Sweden between 2006 and 2011 and were followed up until 2019. Data from the Swedish Arthroplasty Register was used. Medical records and radiographs were studied. The fractures were classified according to the Vancouver classification. The fracture location and anatomy were delineated. We also measured the remaining attachment index (RAI) and the canal thickness ratio. Vancouver type C (n = 101) and spiral fractures (n = 67, 41 in Vancouver C and 26 in Vancouver B) were the most common fracture types. 4 fractures were avulsion of the greater trochanter. The remaining 51 fractures occurred around the stem (B1: 25, B2: 16, and B3: 10). B fractures were more commonly reoperated on (18 of 51, 35%) than type C fractures (11 of 101, 11%, P = 0.001). In most femurs with type B3 fracture, the fracture line covered an area only around the stem, but in all B1 and in 11 of 16 B2 fractures, it was extended even distal to the stem. ORIF instead of stem revision in B2 fractures, use of short stems or plates, and inadequate reduction of the fractures were risk factors for subsequent reoperations. The higher reoperation rate in type B fractures, compared with fractures distal to the stem, could be caused by their higher degree of complexity and reduced capacity for healing in the region around the stem.

The application of an isotropic crushable foam model to predict the femoral fracture risk.

For biomechanical simulations of orthopaedic interventions, it is imperative to implement a material model that can realistically reproduce the nonlinear behavior of the bone structure. However, a proper material model that adequately combines the trabecular and cortical bone response is not yet widely identified. The current paper aims to investigate the possibility of using an isotropic crushable foam (ICF) model dependent on local bone mineral density (BMD) for simulating the femoral fracture risk. The elastoplastic properties of fifty-nine human femoral trabecular cadaveric bone samples were determined and combined with existing cortical bone properties to characterize two forms of the ICF model, a continuous and discontinuous model. Subsequently, the appropriateness of this combined material model was evaluated by simulating femoral fracture experiments, and a comparison with earlier published results of a softening Von-Mises (sVM) material model was made. The obtained mechanical properties of the trabecular bone specimens were comparable to previous findings. Furthermore, the ultimate failure load predicted by the simulations of femoral fractures was on average 79% and 90% for the continuous and discontinuous forms of the ICF model and 82% of the experimental value for the sVM material model. Also, the fracture locations predicted by ICF models were comparable to the experiments. In conclusion, a nonlinear material model dependent on BMD was characterized for human femoral bone. Our findings indicate that the ICF model could predict the femoral bone strength and reproduce the variable fracture locations in the experiments.

Higher Annual Total Hip Arthroplasty Volume Decreases the Risk of Intraoperative Periprosthetic Femur Fractures

BackgroundPeriprosthetic femur fracture (PFF) is a complication of total hip arthroplasty (THA). These occur intraoperatively or postoperatively, and documented risk factors of PFFs include women, age greater than 65 years, cementless stems, and inflammatory arthropathies. The aim of this retrospective cohort study was to assess the relationship of years of surgical experience and surgeon annual THA volume on intraoperative and postoperative PFFs. MethodsData were collected from a database query, and PFFs were identified as either intraoperative or postoperative. Intraoperative and postoperative PFFs were both compared to a control group of non-PFF patients. Years of surgical experience at the time of surgery and annual THA volume for the primary surgeon were calculated for all cases. Logistic regression analyses were used to calculate odds ratios for each of the surgeon variables when adjusted for patient demographics. ResultsThirty-seven intraoperative and 108 postoperative PFFs were identified and compared to 7,629 controls. From regression analyses, high-volume surgeons (≥50 THA/year) had lower odds of intraoperative PFF (adjusted odds ratio (aOR) = 0.40, P = .020) but not postoperative PFF (aOR = 1.02, P = .921). Surgeon experience (≥15 years since board certification at the time of surgery), was not significantly related to either PFF outcomes. For patient factors, age ≥65 years (aOR = 2.30, P < .001) and women (aOR = 2.69, P < .001) were both significant predictors of postoperative PFFs only. ConclusionSurgeons who performed 50 or more THAs per year had significantly fewer intraoperative PFFs than surgeons who did less than 50 THAs per year. Surgeon experience was not significantly related to PFFs.

Does intramedullary nail have advantages over dynamic hip screw for the treatment of AO/OTA31A1-A3? A meta-analysis

BackgroundHip fractures are still unsolved problems nowadays. We evaluated the functional outcomes and complications in the treatment of hip fractures (AO/OTA31A1-A3) to find potential difference and risk between intramedullary nail (IMN) and dynamic hip screw (DHS).MethodWe searched PubMed, Embase, Cochrane library up to 19 June 2023 and retrieved any studies comparing IMN and DHS in treatment of Hip fractures. The main outcomes and complications were extracted from the included studies. The fixed-effect model was selected to pool the data for homogeneous studies (I2 < 50%). Otherwise, the random effects model was selected (heterogeneity, I2 > 50%). The analysis of sensitivity and subgroup was performed to explore the homogeneous studies among studies. The p-value of less than 0.05 was considered statistically significant.Results30 RCT studies were included in this meta-analysis. There were significant difference of in the items of blood loss, screening time, femoral neck shortening, non-union, and femoral fractures (p < 0.05). Significant difference was found in the parameter of open reduction of fracture after sensitive analysis (p < 0.05). No significant difference was found in the parameter of Mobility Score at the last follow-up after sensitive analysis (p ≥ 0.05). There was no significant difference in the parameters of open reduction of fracture, required blood transfusion, mean surgical time, hospital stays, time to healing, mean Harris Hip Score, infection, cut out, poor reduction, breakage of implant, failure of fixation, reoperation, and systemic complications of chest infection, decubital ulcer, urinary tract infection and persistent pain in the hip (p ≥ 0.05).ConclusionsOur meta-analysis revealed that hip fractures treated with IMN have merits with lower rate of blood loss, femoral neck shortening and non-union; shortcoming of increased risk of femoral fractures. It is suggested that special attention should be paid to the risk of femoral fracture when intramedullary nail was inserted in the intraoperative.

Poster 222: High Rates of Conversion to Total Hip Arthroplasty After Core Decompression for Avascular Necrosis of the Hip

Objectives: Avascular necrosis (AVN) of the hip is caused by interruption of blood flow to the femoral head, resulting in pain, loss of joint function, and eventual hip arthritis. Core decompression may be performed for early AVN with a goal of improving symptoms and potentially delaying the need for THA. The effectiveness of this procedure is generally not well understood given the relatively rare nature of hip AVN. The predictors of conversion to THA after core decompression are not well defined. Core decompression is also not without potentially devastating complications, including femoral neck fractures, though estimation of true incidence of complications has been limited by sample sizes in prior investigations. The purpose of this study is to utilize a large payor database to determine time to THA after core compression, assess predictors of early conversion to THA, and to examine complications after hip core decompressions. We hypothesize that less than 25% of patients who had a hip core decompression will convert to THA at two year follow up, we also hypothesize that age at time of core decompression will be a predictor of conversion to THA. Methods: Using Current Procedural Terminology codes, we queried the Mariner PearlDiver dataset for patients who underwent hip core decompression from 2010 to 2020. Patient demographics were recorded and subsequent THA conversion within 2 years after surgery were tracked. Patient demographic factors, including, age, sex, obesity, diabetes, prior fractures, steroid use, tobacco use, or alcohol use, were evaluated as possible predictors of early conversion to THA. International Classification of Diseases, codes were used to identify complications at 90 days and 2 years after core decompression. Multiple linear regression was used to test if the patient demographics significantly predicted conversion to THA and a Cox-Survival plot was performed. Statistical significance was defined as p&lt;.05. Results: Between 2010-2020, 555 patients underwent hip core decompression. Within 2 years of core decompression, 209 patients converted to THA (37.6%) and one patient converted to hemiarthroplasty. Average age for patients converting to THA was 47.7 years compared to those who did not convert 43.4 (95% CI 2.1 – 6.2 years, p &lt; .001). Most patients who converted to a THA were between age 50-59 (Figure 1). Age was the only risk factor for conversion to THA as the following variables were not associated: Sex, obesity, diabetes, prior fracture, steroid use, tobacco use, or alcohol use. Cox survival plot demonstrated a high risk of conversion to THA within two years of core decompression with the highest risk within the first 200-days (Figure 2). 90-day complication rate was 2.9% and the complication rate at 2 years was 5.2%. The most common complication was femoral neck fracture at both time points (68.7% of compilations at 90 days and 75.9% at 2 years). There was no significant difference in demographics between those that had complications and those that did not at 90 days. At 2 years after surgery patients that smoked (OR 0.39 p = .02) or had a prior fracture (OR 0.23; p = .02) were more likely to have had complications. Conclusions: There is a high failure rate following core decompression for hip AVN with over one third of patients converting to THA within 2 years. Patients older than age 50 had the highest rates of conversion to THA. While the overall complication rate is low at 90 days and 2 years, patients should be counseled regarding the risk for femoral neck fracture. Further research is needed regarding predictors of success after core decompression.

Femoral hip osteoporotic fracture risk in Jordanian cohort and their relationships with hypertension and antihypertensive drugs

Background: Osteoporosis and hypertension (HTN) are frequent and often coexisting diseases among the elderly. Recent studies suggested that both diseases may share the same etiopathology. Moreover, the treatment of hypertension can either positively or negatively affect the bone mineral density (BMD) and consequently, either improving or worsening the patients’ osteoporosis statuses, respectively. Aim: The primary aim of this study is to determine the odd ratios, pearson and spearman correlations, and the distribution rates of the HTN statuses and their corresponding anti-HTN medications, in addition to other investigated comparative variables, across two categorized cohorts; the lower risk of femoral hip osteoporotic fracture (fHOPF) cohort [Cohort I] versus the higher fHOPF cohort [Cohort II], in Jordanian cohort. Methods: The investigated studied participants were either allocated to non-HTN versus HTN cohorts (Cohort I vs Cohort II, respectively). Also, the anti-HTN medications were categorized into 6 major medication’s group; Group I-VI. Both aforementioned categorized 2 patients’ cohorts and 6 medications’ groups were analyzed via chi square test to express the comparison results as distribution rates strength of associations (odd ratios), Pearson chi-square statistic (χ 2), Goodness of Fit (G-Test of independence), and Pearson (r) and Spearman (ρ) correlations. Patients who were on thiazide or thiazide like diuretics with ACEIs or ARBs had the lowest incidence rate of higher risk of fHOPF (50%), followed by patients who were on BBs with thiazide or thiazide like diuretics (66.7%), CCBs with thiazide or thiazide like diuretics (85%), CCBs with ACEIs or ARBs (85.7%), and lastly for patients who took CCBs with or without BBS (100%) [R &amp; ρ [-0.390±0.081 &amp;-0.362±0.068], χ 2 &amp; G-Test [18.685 &amp; 18.805], p-Value [0.002 &amp;0.002]]. Results: Overall, 206 participants who were clinically diagnosed for osteoporotic fracture risk at our rehabilitation and rheumatology clinic between Sep 2021 and Nov 2021, were studied to investigate the differences of the various investigated independent variables across the 2 dichotomized HTN related cohorts; Cohort I-II. In this study, 49.03% (101 of the eligible patients) were allocated to the non-HTN affected cohort (Cohort I) and 50.97% (101 of the overall participants) were comparatively allocated to the HTN affected cohort (Cohort II). Conclusion: The thiazide or thiazide like diuretics and ACEIs or ARBs, alone or in combination, may positively improve the femoral hip bone mineral densities and consequently mitigate the risk of osteoporotic fractures.

The safety of levothyroxine use with respect to bone mineral density

Background: Previous studies on bone mineral density (BMD) abnormalities associated with hypothyroidism are scarce and not conclusive. The effect of thyroid hormone therapy on BMD has shown mixed results. Aim: This study aimed primarily to determine the association between the positive history of levothyroxine administering and the risk of osteoporotic fracture in Jordanian cohort of both genders, including post-menopausal women, who were attended to our rehabilitation clinic. Methods: This study trial was an observational study, which was conducted retrospectively at Prince Rashid bin Al-Hasan Military Hospital, Royal Medical Services, Irbid, Jordan. The Binary Logistic Regression (BLgR) analysis was conducted for the 2 contrarily Levothyroxine (Tx) comparative group; Tx dependent cohort (Cohort II) versus Non-Tx dependent cohort (Cohort I), against the probability of being on the higher (versus lower) risk of femoral hip osteoporotic fracture (fHOPF). The studied patients were dichotomously categorized into 2 comparative cohorts; non-Levothyroxine dependent cohort [Cohort I] versus Levothyroxine dependent cohort [Cohort II]. A Chi Square test was processed across these 2 dichotomized cohorts to express the comparison results as Number (Percentages), strength of associations (odd ratios), Pearson chi-square statistic (χ 2), Goodness of Fit (G-Test of independence), and Pearson (r) and Spearman (ρ) correlations. Results: The BLgR analysis results revealed that the unadjusted risk ratio for the higher probability of fHOPF in our investigated patients, who were on Thyroxine therapy [Tx dependent cohort, Cohort II] compared to the Tx independent cohort [Cohort I], was 10.969 (95% CI; 4.615-26.072). The explained variations in the fHOPF risk related Tx dependent status on our model of this BLgR based model ranged from 17.9%-23.8% (depending on the inferential Cox &amp; Snell R2 or Nagelkerke R2 methods, respectively) and correctly classified approximately 61.2% of the overall cases. The constructed BLgR model was formulated as {e (-0.627+2.395×Tx)/[1+ e (-0.627+2.395×Tx)]}. Conclusion: We revealed that the patients who were used thyroxine therapies (Cohort II patients) had significantly higher proportional distribution of higher risk of fHOPF compared to Cohort I patients [41 (85.4%) vs 55 (34.8%), respectively] with an odd ratio of 10.969 (95% CI; 4.62-26.07) and significant positive correlation of 0.429±0.057, χ2=37.889, p-value=0.000.

Systematic Review and Meta-Analysis of Studies Comparing the Rate of Post-operative Periprosthetic Fracture Following Hip Arthroplasty With a Polished Taper Slip versus Composite Beam Stem

BackgroundWe compared the incidence of postoperative periprosthetic femoral fractures (POPFF) following hip arthroplasty with either a cemented polished taper slip (PTS) stem or a cemented composite beam (CB) stem in comparative studies. MethodsA systematic review of comparative studies, written in English and published in peer-reviewed journals since the year 2000, was conducted. Study quality was assessed using the Newcastle-Ottawa scale.The overall study qualities were good. There were 913,021 patients from 18 cohorts included in the meta-analysis. There were 294,540 patients who received a CB stem and 618,481 received a PTS stem. Cohorts were classified as high- or low-risk for POPFF based on patient risk factors. A metanalysis was performed using a random effects model, and the relative incidence with 95% confidence intervals (CIs) was reported. ResultsThe patients at low risk of POPFF had an incidence rate ratio of 3.14 (CI: 2.48, 3.98) for the PTS group versus the CB group. Whereas, the patients at high risk of POPFF had an incidence rate ratio of 9.87 (CI: 3.63, 26.80) for the PTS group versus the CB group. ConclusionsThe risk of POPFF is lower when hip arthroplasty was performed using a CB stem versus a PTS stem. This protective effect was greatest in patients who had a higher risk of POPFF. Surgeons should consider the effect of cemented stem choice on the risk of subsequent periprosthetic femur fracture, particularly in frail or elderly patients who are at a higher risk of postoperative periprosthetic femoral fracture.

Periprosthetic Occult Femoral Fracture: An Unknown Side Effect of Press-Fit Fixation in Primary Cementless Total Hip Arthroplasty.

The objectives of this study were to examine the prevalence and risk factors for development of periprosthetic occult femoral fractures during primary cementless total hip arthroplasty (THA) and to assess the clinical consequences of these fractures. A total of 199 hips were examined. Periprosthetic occult femoral fractures were defined as fractures not detected intraoperatively and on postoperative radiographs, but only observed on postoperative computed tomography (CT). Clinical, surgical, and radiographic analysis of variables was performed for identification of risk factors for periprosthetic occult femoral fractures. A comparison of stem subsidence, stem alignment, and thigh pain between the occult fracture group and the non-fracture group was also performed. Periprosthetic occult femoral fractures were detected during the operation in 21 (10.6%) of 199 hips. Of eight hips with periprosthetic occult femoral fractures that were detected around the lesser trochanter, concurrent periprosthetic occult femoral fractures located at different levels were detected in six hips (75.0%). Only the female sex showed significant association with an increased risk of periprosthetic occult femoral fractures (odds ratio for males, 0.38; 95% confidence interval, 0.15-1.01; P=0.04). A significant difference in the incidence of thigh pain was observed between the occult fracture group and the non-fracture group (P<0.05). Occurrence of periprosthetic occult femoral fractures is relatively common during primary THA using tapered wedge stems. We recommend CT referral for female patients who report unexplained early postoperative thigh pain or developed periprosthetic intraoperative femoral fractures around the lesser trochanter during primary THA using tapered wedge stems.

Rectangular Taper Stem Designs Are Associated With a Higher Risk for Periprosthstic Femoral Fractures After Cementless Total Hip Arthroplasty

BackgroundPeriprosthetic femoral fractures (PFFs) remain a major concern following cementless total hip arthroplasty (THA). This study aimed to evaluate the association between different types of cementless tapered stems and the risk of postoperative PFF. MethodsA retrospective review of primary THAs performed at a single center from January 2011 to December 2018 included 3,315 hips (2,326 patients). Cementless stems were classified according to their design. The incidence of PFF was compared between flat taper porous-coated stems (type A), rectangular taper grit-blasted stems (type B1), and quadrangular taper hydroxyapatite-coated stems (type B2). Multivariate regression analyses were performed to identify independent factors related to PFF. The mean follow-up duration was 61 months (range, 12 to 139). Overall, 45 (1.4%) postoperative PFFs occurred. ResultsThe incidence of PFF was significantly higher in type B1 stems than in type A and type B2 stems (1.8 versus 0.7 versus 0.7%; P = .022). Additionally, more surgical treatments (1.7 versus 0.5 versus 0.7%; P = .013) and femoral revisions (1.2 versus 0.2 versus 0%; P = .004) were required for PFF in type B1 stems. After controlling for confounding variables, older age, diagnosis of hip fracture, and use of type B1 stems were significant factors associated with PFF. ConclusionType B1 rectangular taper stems were found to have higher risks for postoperative PFF and PFF requiring surgical management than type A and type B2 stems in THA. Femoral stem geometry should be considered when planning for cementless THA in elderly patients who have compromised bone quality.

Collared fully hydroxyapatite-coated stem decreases the risk of early postoperative periprosthetic femoral fracture after direct anterior total hip arthroplasty

PurposePostoperative periprosthetic femoral fracture (PPFF) is one of the major complications following total hip arthroplasty (THA). The purpose of this study was to investigate the epidemiology of early PPFF (within 90 days) after THA. MethodsPrimary THA was performed for hip osteoarthritis through a direct anterior approach in 6769 cases. Among these, we retrospectively investigated the occurrence of postoperative PPFF that required surgical intervention. ResultsPostoperative PPFF was seen in 29 hips (29/6769; 0.43%), and the mean period from primary THA to fracture occurrence was 9.2 ​± ​8.5 days. Of these, 13 (13/2170; 0.60%) fractures were observed in prosthesis with flat tapered-wedge stems, 7 (7/1652; 0.42%) in straight tapered stems, 4 (4/1082; 0.37%) in cemented stems, and 1 (1/1.060; 0.09%) in collared fully hydroxyapatite-coated stem. The prevalence of PPFF in collared fully hydroxyapatite-coated stems was significantly lower than that of flat tapered-wedge stems. Five hips (5/29; 17.2%) required re-surgical intervention. ConclusionOur results indicate that, compared to the flat tapered-wedge stem, use of the collared fully hydroxyapatite-coated stem decreases the risk of early postoperative PPFF following direct anterior THA.

Hypnotics and injuries among older adults with Parkinson’s disease: a nested case–control design

BackgroundPatients with Parkinson’s disease often experience sleep disorders. Hypnotics increase the risk of adverse events, such as injuries due to falls. In this study, we evaluated the association between hypnotics and injuries among older adults with Parkinson’s disease.MethodsThe study used a nested case–control design. The participants were 5009 patients with Parkinson’s disease aged ≥ 75 years based on claims data between April 2016 and March 2019 without prescription hypnotics 1 year before the study started. Hypnotics prescribed as oral medications included benzodiazepines, non-benzodiazepines, orexin receptor antagonists, and melatonin receptor agonists. The incidences of outcomes, including injuries, fractures, and femoral fractures, were determined. Each case had four matched controls. Conditional logistic regression analyses were performed to calculate the odds ratios and 95% confidence intervals for the number of hypnotics taken per day for each type of hypnotic.ResultsThe proportion of participants taking at least one type of hypnotic was 18.6%, with benzodiazepines being the most common. The incidence of injuries, fractures, and femoral fractures was 66.7%, 37.8%, and 10.2%, respectively. Benzodiazepines significantly increased the risk of injuries (odds ratio: 1.12; 95% confidence interval: 1.03–1.22), and melatonin receptor agonists significantly increased the risk of femoral fractures (odds ratio: 2.84; 95% confidence interval: 1.19–6.77).ConclusionsBenzodiazepines and non-benzodiazepines, which are not recommended according to current guidelines, were the most prevalent among older adults with Parkinson’s disease. Benzodiazepines significantly increased the risk of injuries, and melatonin receptor agonists significantly increased the risk of femoral fractures.

Risk of Interprosthetic Femur Fracture Is Associated with Implant Spacing-A Biomechanical Study.

Ipsilateral revision surgeries of total hip or knee arthroplasties due to periprosthetic fractures or implant loosening are becoming more frequent in aging populations. Implants in revision arthroplasty usually require long anchoring stems. Depending on the residual distance between two adjacent knee and hip implants, we assume that the risk of interprosthetic fractures increases with a reduction in the interprosthetic distance. The aim of the current study was to investigate the maximum strain within the femoral shaft between two ipsilateral implants tips. A simplified physical model consisting of synthetic bone tubes and metallic implant cylinders was constructed and the surface strains were measured using digital image correlation. The strain distribution on the femoral shaft was analyzed in 3-point- and 4-point-bending scenarios. The physical model was transferred to a finite element model to parametrically investigate the effects of the interprosthetic distance and the cortical thickness on maximum strain. Strain patterns for all parametric combinations were compared to the reference strain pattern of the bone without implants. The presence of an implant reduced principal strain values but resulted in distinct strain peaks at the locations of the implant tips. A reduced interprosthetic distance and thinner cortices resulted in strain peaks of up to 180% compared to the reference. At low cortical thicknesses, the strain peaks increased exponentially with a decrease in the interprosthetic distance. An increasing cortical thickness reduced the peak strains at the implant tips. A minimum interprosthetic distance of 10 mm seems to be crucial to avoid the accumulation of strain peaks caused by ipsilateral implant tips. Interprosthetic fracture management is more important in patients with reduced bone quality.

Cemented Femoral Stem Fixation: Back to the Future

BackgroundPeriprosthetic fractures following elective and nonelective hip arthroplasty remain one of the most common modes of early failure. MethodsThis symposium will explore the current role of cemented fixation and periprosthetic fracture, focusing on history and rationale for cemented stem fixation, registry data, and other potential advantages of cemented stem fixation. A meticulous and methodical surgical technique of cemented stem fixation is paramount to the success and will be thoroughly discussed. ResultsThe role of stem fixation, and its effect on periprosthetic fracture is well-documented in the literature. Yet despite this, the utilization of cemented stem fixation remains low in the United States. This paradox is multifactorial. ConclusionIn addition to a notable reduction in the risk of periprosthetic femur fractures, cemented stem fixation has numerous other advantages and is reproducible with a methodical surgical technique.

Early Changes in the Bone Mineral Density on Dual-energy X-ray Absorptiometry Scan of Patients Undergoing Primary Cemented Total Knee Arthroplasty: A Prospective Cohort Study

Background: The known risk factors of osteoarthritis (OA) knee are aging and obesity while the risk factors of osteoporosis are aging and low body weight, so the relationship between all three is complex. Currently, the dual-energy X-ray absorptiometry (DXA) test is the gold standard in osteoporosis diagnostics. Many epidemiologic studies have revealed increased bone mineral density (BMD) in individuals with OA knee. The impact of total knee arthroplasty (TKA) on BMD levels is not fully understood. Concern has been raised regarding the increased risk of femoral and spine fractures early after TKA. Hence, we conducted this study to measure the BMD changes in the hip and spine in patients receiving TKA. Materials and Methods: It was a prospective interventional cohort study conducted from December 2018 to December 2020. The study included 43 patients admitted for elective TKA after applying the relevant inclusion and exclusion criteria. Patients were analyzed with DXA scans both preoperatively and 6 months postoperatively. Results: When we studied all the patients as one single sample, the initial observation was that at the 6-month follow-up, the patients showed a statistically significant improvement in the femur BMD score while the change in spine BMD was statistically insignificant. However, when subsets of the study sample, i.e. preoperatively normal, osteopenic, and osteoporotic patients, underwent further analysis, we found that out of 18 patients having normal BMD preoperatively, one patient developed osteopenia and another developed osteoporosis upon postoperative follow-up DXA scan. Similarly, one out of the eight patients, having osteoporosis preoperatively, improved a grade to osteopenia upon postoperative follow-up DXA scan. However, these changes were not statistically significant. Conclusions: we conclude that there is no statistically significant change in both the femur and the spine BMD at least 6-month follow-up postprimary TKA.