Risk Of Intraoperative Fracture Research Articles

Intraoperative complications in patients with systemic lupus erythematosus during total hip replacement

BACKGROUND: Systemic lupus erythematosus (SLE) is a chronic disease of unknown etiology characterized by systemic immuno-inflammatory damage to vital organs. A serious complication of SLE is aseptic bone necrosis, which is characterized by severe pain syndrome, impaired joint function, decreased quality of life and disability. Despite the fact that hip replacement is a technically proven method of surgical treatment, patients with SLE are still at increased risk of complications at all stages of the perioperative period.AIM: the aim of the work is to describe the effect of SLE on the development of intraoperative complications during hip replacement.MATERIALS AND METHODS: The study included 133 patients diagnosed with SLE who underwent total hip replacement between 1998 and 2021. All surgical interventions were performed in the traumatology and orthopaedic department. The group of patients with SLE was dominated by women, the ratio of women to men was 7.3:1, respectively. The average age of patients at the time of surgery was 36.6±12.6 years.RESULTS: Hip replacement in all patients (n=133) was performed as standard in the patient’s position on the healthy side from the anterolateral Harding access. In 75 cases (56.3%), additional fixation of the acetabulum component with screws was performed. In 10 cases, a cerclage was applied to the proximal femur due to a fracture that occurred during the development of the bone marrow canal. To clarify the factors influencing the development of an intraoperative fracture, patients with SLE were divided into 2 groups: the first group (n=10) — with an intraoperative fracture, the second (n=123) — without a fracture. The comparative characteristics of the first and second groups are carried out. Another complication at the stage of surgical treatment is an increased volume of blood loss, which required transfusion of erythrocyte suspension. There were 54 such patients (40.6%). In relation to patients with increased blood loss, we compared the clinical and laboratory characteristics of patients immediately before surgical treatment, with and without increased blood loss.CONCLUSION: In the study, we analyzed the resulting intraoperative complications. We have not received confirmation of the effect of daily and cumulative doses of HA, as well as the degree of activity and course of SLE on the risk of intraoperative fracture. The probability of fracture was significantly higher in patients with initially reduced bone mineral density. With regard to the increased volume of blood loss in patients with SLE, a significant association was found with baseline anemia (reduced hemoglobin and hematocrit levels) in the preoperative period (p<0.001).

Uncemented reverse total shoulder arthroplasty: is it a safe option for elderly patients with proximal humerus fractures?

Reverse shoulder arthroplasty (RSA) is a common surgical procedure for elderly patients with proximal humerus fractures. Cement fixation of the humeral stem is considered the gold standard for this procedure. Due to the high prevalence of osteoporosis in this patient population, the risk of intraoperative fractures is increased when uncemented stems are used. Stem loosening is another concern of uncemented stems. However, the use of cement is associated with the risk of cement embolisation, impairment of tuberosity healing, and technical difficulties for later revisions. This study aimed (i) to evaluate the clinical and radiological outcomes of patients treated with uncemented RSA for proximal humerus fractures at two years postoperatively, and (ii) to compare these outcomes between patients with and without decreased low bone quality as measured by the deltoid tuberosity index. The single-centre prospective study included 54 shoulders (52 patients) with a proximal humerus fracture between 2019 and 2022. Enrolled were patients aged 65 and older with acute or secondary displaced three- or four-part fractures or head-split fractures treated with RSA using the same uncemented system and tubercula refixation. At 24 months post-surgery, clinical evaluations included range of motion (ROM), Constant-Murley Score (CS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons (ASES) Score. Radiological assessments evaluated scapular notching, radiolucent lines, and greater tuberosity healing. The mean age was 79 years (± 8), 87% were female, and 69% had osteoporotic fractures. At the two-year follow-up, the median SSV was 90% (IQR 80-95), the median CS Score was 76.5 (IQR 72-81), and the median ASES Score was 89.9 (IQR 82-93). The ROM measurements were: median active forward flexion 140° (IQR 120-160), median external rotation 30° (IQR 20-40), and median active internal rotation 6 (IQR 4-8). The greater tuberosity healing rate was 94.5%. Although osteoporotic fractures occurred more often in older patients (mean 81 vs. 72 years, respectively), no other significant differences were detected between the groups. One case of aseptic stem loosening occurred in the non-osteoporotic group. Even in osteoporotic proximal humerus fractures, cementless stems combined with tubercula refixation resulted in favourable outcomes and were not associated with increased complications.

A comparison of the clinical efficacy of total hip arthroplasty via direct anterior approach and posterior approach: A meta-analysis.

The approach of total hip arthroplasty (THA) has long been controversial, and many studies have compared different approaches. However, there is still a lack of consistent conclusions and comprehensive, systematic comparisons and evaluations. This study retrieved 7 databases: PubMed, Web of Science, Embase, Cochrane Library, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, and Wanfang Database. The search time ranged from the establishment of each database to November 1, 2023. Data analysis was performed using Review Manager 5.4, and outcome was presented as the weighed mean difference for continuous data and risk/odds ratio for dichotomous data. We used the Mantel-Haneszel method and random effects model to obtain the overall effects of the differences in the impact of 2 surgical methods on clinical outcomes in all included studies. A total of 33 articles were included in this study, including 14478 participants, 4911 participants in DAA group and 9567 participants in PA group. The visual analogue scale scores of the DAA group at 1 day and 2 days after THA were significantly lower than those of the PA group (mean difference [MD] = -0.56, 95% confidence interval [CI]: -0.83 to -0.30, P < .01) at 1 day and (MD = -0.67, 95% CI: -1.16 to -0.17, P = .01) at 2 days. The risk of intraoperative fracture (odds ratio = 2.18, 95% CI: 1.11-4.29, P = .05) and lateral femoral nerve injury (risk ratio = 7.84, 95% CI: 1.69-36.42, P < .01) in the DAA group was significantly higher than that of the PA group. The number of prostheses in the Lewinnek safe zone of the DAA group was significantly higher than that of the PA group (risk ratio = 1.13, 95% CI: 1.00-1.27, P = .05). The results showed no significant difference between the DAA group and the PA group in the time to stop using walking aids, dislocation rate, groin pain, incision complications, heterotopic ossification, intraoperative blood loss, and acetabular anterior (P > .05). Compared with the PA group, patients in the DAA group showed more ideal anatomical and imaging results, shorter hospital stay, and showing advantages in postoperative pain, but with a higher incidence of intraoperative complications.

Iatrogenic Intraoperative Fracture in Patients With Osteogenesis Imperfecta.

Osteogenesis imperfecta (OI) is a genetic defect in collagen type I, phenotypically characterized by bony fragility and a propensity to high rates of childhood fracture. Fragility fractures in patients with OI have been reported with routine hospital care. In addition, there is a nonzero rate of iatrogenic fracture during orthopaedic surgery directly related to the technical steps of the procedure itself. The rate of this latter has never been explicitly investigated. A review of all patients at a single OI referral center was conducted, including all patients with a diagnosis of OI seen between 2013 and 2023, inclusive. All patients who underwent orthopaedic surgery of any kind were reviewed, and clinical and radiographic details of all procedures were extracted. Among the details examined were the OI subtype, surgery details, any implants used, intraoperative and hospital stay complications, modified Clavien-Dindo classification of complications, and ultimate outcome. Eleven of 60 patients experienced an unplanned, iatrogenic intraoperative fracture during orthopaedic surgery (11/60 = 18.3%). This comprised 15 fractures among 356 total orthopaedic surgical episodes (15/356 = 4.2%). All but one fracture occurred on the operative long bone segment, all were a direct result of surgical steps, and 11 of 15 fractures occurred in the femur. Most fractures were secondary to the removal, insertion, or exchange of intramedullary implants in the lower extremity (11 of 15 fractures), most often the femur. Thirteen of 15 injuries were classified as modified Clavien-Dindo II or III, requiring modification of postop rehabilitation, additional treatments, or surgical intervention (87%). Overall, iatrogenic fracture was the most common intraoperative complication experienced in the cohort. Iatrogenic fracture during orthopaedic surgery for patients with OI is not uncommon. A sizeable minority of patients with OI undergoing orthopaedic surgery will experience unplanned fractures, most commonly in the femur, and care is altered in most instances. The risk of intraoperative fracture can be discussed with families of children with OI as part of informed consent and shared decision-making. Level IV-retrospective cohort series.

Cannula breakage during 25G+ minimally invasive vitrectomy: a case report

BackgroundWith the continuous improvement of surgical instruments in vitrectomy, the use of a trocar and cannula not only optimizes the incision process but also facilitates insertion and withdrawal of instruments during the procedure. Nevertheless, incision-related complications have also been reported in the literature. However, cannula fractures during 25G+ minimally invasive vitrectomy have rarely been reported.Case presentationA 62-year-old man underwent 25G+ pars plana vitrectomy for proliferative diabetic retinopathy. At the beginning of the operation, we used a trocar with a cannula to perform the sclerotomy. After the trocar was pulled out, the cannula was not seen on the surface of the sclera. Thus the inside and outside of the eye were carefully searched. The broken cannula tip was found in the ciliary body corresponding to the superonasal sclerotomy site and was subsequently removed.ConclusionsAwareness regarding the risk of intraoperative fractures of 25G+ minimally invasive ocular surgical instruments is imperative. Whenever a broken or missing cannula is encountered, the residual part should be immediately extracted to avoid revision surgeries and postoperative complications.

Comparison of outcomes after reverse shoulder arthroplasty in patients with rheumatoid arthritis and cuff tear arthropathy

Background The reverse shoulder arthroplasty (RSA) was originally designed for cuff tear arthropathy (CTA). Over time, the indications have expanded to rheumatoid arthritis (RA). This study aimed to compare the outcomes of RSA in patients with RA and CTA to determine if there is any impact on clinical and radiographic outcomes. Methods In this retrospective comparative study (performed from August 2010 to March 2017), 61 shoulders from 59 consecutive patients (RA group: 24 patients [26 shoulders], CTA group: 35 patients [35 shoulders]) who underwent primary RSA, were included. The average follow-up period was 31 months (range, 24-64 months). Patients were assessed with the use of the visual analog scale pain score, the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, the Single Assessment Numeric Evaluation score, range of motion (ROM), and imaging studies included the β angle, glenoid component superior tilt, and scapular notching. Results The clinical results improved significantly in both groups, but there was no statistically significant difference between the RA group and the CTA group. Significant intergroup differences were observed regarding the β angle (73° ± 11° for the RA group vs. 85° ± 8° for the CTA group; P Conclusion Compared with CTA patients, RA patients achieved similar clinical outcomes following RSA. However, surgeons should pay attention to the positioning of the glenoid component during the surgery and the risk of intraoperative fractures in RA patients.

Cross-screw technique for the modified Lapidus procedure using headless compression screws

Aims: The aim was to evaluate union rates using two cross headless compression screws for the modified Lapidus procedure. This was compared to conventional fixation using solid AO screws and plates, as recorded in the published literature. Patients and methods: This is a retrospective study of the modified Lapidus procedure performed in patients with a moderate to severe hallux valgus deformity. Union time and patient demographics were retrieved from medical records. Patient demographics included age, sex, smoking habits and other comorbidities. The union rate was compared to the literature using the two-population probability test, with p<0.05 being significant. Results: Sixty-nine feet in 56 patients were assessed for radiographic union. There were three delayed unions and two non-unions. The union rate of 97% was not statistically different when compared to studies using conventional solid AO screws. Conclusion: The use of headless compression screws in the fixation of the first tarsometatarsal joint and early mobilisation was found to be comparable to conventional solid AO screws with regard to union rates. The cannulated design enhances ease of insertion and, being headless, minimises the risk of intra-operative fracture and hardware prominence requiring subsequent removal. Level of evidence: Level 4

What Are the Risk Factors and Complications Associated With Intraoperative and Postoperative Fractures in Total Wrist Arthroplasty?

Total wrist arthroplasty (TWA) can relieve pain and preserve some wrist motion in patients with advanced wrist arthritis. However, few studies have evaluated the risks and outcomes associated with periprosthetic fractures around TWAs. (1) What is the risk of intraoperative and postoperative fractures after TWAs? (2) What factors are associated with increased risk of intraoperative and postoperative fracture after TWAs? (3) What is the fracture-free and revision-free survivorship of TWAs among patients who sustained an intraoperative fracture during the index TWA? At one institution during a 40-year period, 445 patients underwent primary TWAs. Of those, 15 patients died before 2 years and 5 were lost to followup, leaving 425 patients who underwent primary TWAs with a minimum of 2-year followup. The primary diagnosis for the TWA included osteoarthritis ([OA] 5%), inflammatory arthritis (90%), and posttraumatic arthritis (5%). Indications for TWA included pancarpal arthritis combined with marked pain and loss of wrist function. The mean age of the patients was 57 years, BMI was 26kg/m2, and 73% were females. Six different implants were used during the 40-year period. Mean followup was 10 years (range, 2-18 years). Intraoperative fractures occurred in nine (2%) primary TWAs, while postoperative fractures occurred after eight (2%) TWAs. After analyzing demographics, comorbidities, and surgical factors, intraoperative fractures were found to be associated with only age at surgery (hazard ratio [HR], 1.10; 95% CI, 1.03-1.20; p = 0.006) and use of a bone graft (HR, 5.80; 95% CI, 1.18-23.08; p = 0.03). No factors were found to be associated with increased risk of postoperative fractures; specifically, intraoperative fracture was not associated with subsequent fracture development. The 5-, 10-, and 15-year Kaplan-Meier survival rates free of postoperative fracture were 99%, 98%, and 95%, respectively. The 5- and 10-year revision-free survival rates after intraoperative fracture were 88% and 88%, respectively, compared with 84% and 74% without an intraoperative fracture (p = 0.36). Furthermore, the survival-free of revision surgery rates for aseptic distal loosening at 5 and 10 years were 88% and 88%, respectively, compared with 93% and 87% without a fracture (p = 0.85). Intraoperative fractures occur in approximately 2% of TWAs. These fractures do not appear to affect long-term implant survival or risk of fracture. Patient age and the need for bone graft were the only factors in the risk of intraoperative fractures. Postoperative fractures also occur in 2% of TWAs, but often result in revision surgery. Level III, therapeutic study.

Prevalence and risk factors for intra-operative periprosthetic fractures in one thousand eight hundred and seventy two patients undergoing total hip arthroplasty: a cross-sectional study.

The purpose of this study was to identify the frequency and type of intra-operative periprosthetic fractures and to describe risk factors in a single tertiary, public hospital, so that these events could be prevented, even among less experienced surgeons. This is a cross-sectional study, based on medical records and imaging exams from the archives of a public, tertiary hospital, from April 1998 to October 2013. All consecutive patients submitted to total hip arthroplasty (THA) in the study period were evaluated, excluding unipolar or bipolar arthroplasty, surgery for the osteosynthesis of periprosthetic fractures, surgical procedure to clean infection site without component substitution and not arthroplastic surgery. Data were analyzed with chi-squared test and multivariate Cox regression. In the study period, 1,872 THA (1,728 patients) were performed and analyzed, with 144 bilateral cases. In 173 cases, patients had undergone surgical procedures other than THA previously, and in only 260 the surgery consisted of revision THA. There were only two cases of resection THA. Among all patients 101 intra-operative periprosthetic fractures occurred. The univariate analysis revealed a significantly higher risk of intra-operative fractures in female patients, aged more than 65 years, with indication of primary THA and the presence of a previous hip surgery. It indicated also that revision surgeries were associated with a 2.8-fold higher risk of intra-operative fracture, 2.18-fold risk in a previously operated hip and 3.9-fold in cases of resection THA or revision surgery in two stages. Intraoperative periprosthetic fracture is a rare event, and it is associated with revision type surgery and THA in a previously operated hip.

Intraoperative Fracture of the Femur in Revision Total Hip Arthroplasty with a Fully HA-Coated Stem

A retrospective review was made of intraoperative femoral fracture prevalence in seventy nine consecutive, cementless, fully HA-coated stems used for revision hip arthroplasty. Three patients were lost to follow up. Intraoperative fracture occurred in 15 (20%) femurs. Fractures occurred during cement removal (3/15) or insertion of the implant (12/15). All fractures were identified using intraoperative biplane X-ray, and were treated during the same operation. The clinical outcome of both groups (with or without fractures) was similar. The risk of intraoperative fracture was not statistically related to any demographic features or operative technique. Intraoperative radiographs are therefore mandatory in revision hip arthroplasty in order to diagnose and treat the common complication of femur fracture appropriately.

Do Retained Pediatric Implants Impact Later Total Hip Arthroplasty?

It is debated whether all pediatric implants in the proximal femur should be removed in childhood. Hardware removal requires an additional surgical procedure and may put the child at risk for postoperative fracture. However, the impact of retained pediatric implants on future surgeries such as total hip arthroplasty (THA) is not well-understood. We undertook this case-control study to evaluate the effect of retained pediatric implants on surgical complexity and complications at the time of THA. This may offer insight as to whether pediatric proximal femoral implants should be removed in childhood. Case-control study. Between 1990 and 2007, 15,601 primary THAs were performed at a tertiary referral center. Of those, 31 hips had pediatric hardware that had been implanted at a mean of 31 years before the time of THA. Perioperative course and complications were compared with an age-matched, sex-matched, and BMI-matched cohort of 31 patients with no retained implants. Mean follow-up after arthroplasty was 7 years. Operative time was significantly longer in the retained implant group compared with the control group (230 vs. 159 min; P<0.0001), as was the hospital stay (5.2 vs. 3.8 d; P=0.02). Four of the 14 patients with retained plates required a strut allograft at the time of primary THA. Revision femoral stems and bone grafting were more frequently required in the retained implant cohort. Estimated blood loss was also higher in the retained implant cohort (886 vs. 583 mL; P=0.031). Seven patients in the retained hardware group had a major complication, including intraoperative fracture (5), bleeding (1), and nerve injury (1), whereas no patients in the control group sustained major complications (P=0.017). Retained pediatric implants removed at the time of THA were associated with increased operative time, length of stay, and risk of intraoperative fracture. This data supports routine removal of proximal femoral implants in pediatric patients with a high likelihood of future THA. III, case-control study.

Hip hemiarthroplasty for femoral neck fractures using the modified stracathro approach - Short term results in twenty-six patients

Background and Objective:The Stracathro approach to the hip is a modification of the lateral approach, which was popularized by Hays and McLauchlan. It has a high safety profile and a low rate of hip dislocation. However, the need for osteotomy increases blood loss, risk of intraoperative fracture, and postoperative heterotopic calcification. In sub-Saharan Africa, where traditional healers dabble in the treatment of all musculoskeletal conditions, extensive soft tissue contractures and disuse osteoporosis arise and further complicate the lateral approach. The objective of this article is to highlight modifications made to the stracathro approach and present the short-term results in a group of 26 patients, who had hemiarthroplasty using this technique.Materials and Methods:All patients presenting with subcapital or transcervical fracture of the femoral neck after the age of 50 years were offered hemiarthroplasty using the modified Stracathro approach, with follow-ups for a period ranging from 28 – 84 months.Results:A majority (23 out of 26 – 88.5%) of patients presented late for the treatment, due to the patronage of traditional bonesetters. In spite of the soft tissue contractures and osteoporosis associated with late presentation, there was no case of intraoperative fractures. The patients had good hip abduction postoperatively. In addition, there was no intraoperative nerve or vascular injury.Conclusion:The short-term results in this group of patients showed that the modified Stracathro approach was safe and useful in hemiarthroplasty, for patients with soft tissue contracture and osteoporosis.

A simple guide to determine the magnification of radiographs and to improve the accuracy of preoperative templating.

Templates are used in the preoperative planning of many orthopaedic procedures. The magnification of the bones on preoperative radiographs can vary despite using standardised radiological techniques. Templates will give misleading measurements unless this magnification is quantified. A coin may be used to calculate the magnification, with significant improvement in the accuracy of templating (p = 0.05). A group of patients undergoing uncemented arthroplasty of the hip was at high risk for intraoperative fracture of the femur because the magnification of the radiograph was larger than that of the template.

Impaction bone grafting in revision hip surgery

We have reviewed retrospectively 68 revisions of the femoral component in arthroplasties of the hip in 65 patients, using impaction bone grafting, at a median of three years (1 month to 6 years). We employed the cemented Exeter X-Change technique in 36 patients and the uncemented Bi-Metric allografting method in 32. The 37 bone defects were grade 3 or grade 4 on the Endo-Klinik classification. The Mayo hip score improved from a mean of 32 (sd ± 18) to 62 (sd ± 15). Most (25) of the 34 complications occurred in grade-3 and grade-4 defects; nine were intraoperative diaphyseal fractures and eight fractures of the greater trochanter. All the fractures united. The risk of intraoperative fracture was prevented by supporting the bone with wires in 16 hips, with reinforcement mesh in 18 and by a plate in six. Early migration of the stem of more than 10 mm during the first year indicated rotational instability; it occurred in three cases. In difficult revision cases with large defects of the femoral bone, bone-impaction techniques carry a high risk of complications.

Impaction bone grafting in revision hip surgery. A high incidence of complications.

We have reviewed retrospectively 68 revisions of the femoral component in arthroplasties of the hip in 65 patients, using impaction bone grafting, at a median of three years (1 month to 6 years). We employed the cemented Exeter X-Change technique in 36 patients and the uncemented Bi-Metric allografting method in 32. The 37 bone defects were grade 3 or grade 4 on the Endo-Klinik classification. The Mayo hip score improved from a mean of 32 (SD +/- 18) to 62 (SD +/- 15). Most (25) of the 34 complications occurred in grade-3 and grade-4 defects; nine were intraoperative diaphyseal fractures and eight fractures of the greater trochanter. All the fractures united. The risk of intraoperative fracture was prevented by supporting the bone with wires in 16 hips, with reinforcement mesh in 18 and by a plate in six. Early migration of the stem of more than 10 mm during the first year indicated rotational instability; it occurred in three cases. In difficult revision cases with large defects of the femoral bone, bone-impaction techniques carry a high risk of complications.

Total hip arthroplasty in patients with proximal femoral deformity.

Most proximal femoral deformities encountered during hip arthroplasty are secondary to developmental processes, previous osteotomy, or fracture. A classification method is proposed in which deformities are categorized anatomically by level. Anatomic deformity levels include: greater trochanteric deformities, femoral neck deformities, metaphyseal level deformities, and diaphyseal level deformities. Deformities at each level may be angular, rotational or translational, abnormal bone size, or a combination thereof. Treatment is individualized according to patient needs and the anatomy of the deformity. Careful preoperative planning helps predict prosthesis requirements and technical challenges. If cemented implants are used, care must be taken to obtain reasonable alignment and a continuous cement mantle. For uncemented implants, obtaining a good fit is challenging and there is a risk of intraoperative fracture. Access to a wide range of implants helps the surgeon treat unique femoral geometries. Implants fixed in the diaphysis allow some proximal femoral deformities to be bypassed. Modular or custom implants simplify treatment of certain deformities. For patients with severe deformities, femoral osteotomy may be required. Successful osteotomy requires correcting the deformity, maintaining vascular supply of fragments, obtaining fixation of osteotomy fragments (with the implant or adjunctive fixation), and obtaining implant stability. Although most deformities can be treated during hip arthroplasty, occasionally there is a role for two-stage treatment: deformity correction followed later by arthroplasty.