Bone cement implantation syndrome

Postoperative 30-day complications after cemented/hybrid versus cementless total hip arthroplasty in osteoarthritis patients > 70 years

Background and purpose - The use of cementless total hip arthroplasty (THA) in elderly patients is debated because of increased risk of early periprosthetic femoral fractures. However, cemented femoral components carry a risk of bone cement implantation syndrome. Hence, we compared in-hospital complications, complications leading to readmission and mortality ≤ 30 days postoperatively between hybrid/cemented (cemented femoral component) vs. cementless THA in osteoarthritis patients > 70 years.Patients and methods - This is a prospective observational cohort study in 9 centers from January 2010 to August 2017. We used 30-day follow-up from the Danish National Patient Registry, patient records, and data from the Danish Hip Arthroplasty Register. Only THAs performed as a result of osteoarthritis were included.Results - 3,368 (42%) of the THAs were cemented/hybrid and 4,728 (58%) cementless. The in-hospital complication risk was 7.7% after cemented/hybrid vs. 5.3% after cementless THA (< 0.001), statistically not significant when adjusting for comorbidities (p = 0.1). There were similar risks of complications causing readmission (5.7% vs. 6.2%) and mortality ≤ 30 days (0.2% vs. 0.3%). 15 cases (0.4%) of pulmonary embolism (PE) were found after cemented/hybrid vs. 4 (0.1%) after cementless THA (p = 0.001); none occurred within 24 hours postoperatively. 2 of the PEs after cementless THA led to mortality. Cemented/hybrid THA remained significantly associated with risk of PE (RR 3.9, p = 0.02), when adjusting for comorbidities. BMI > 35 was associated with highest risk of PE (RR 5.7, p = 0.003). The risk of periprosthetic femoral fracture was 0.2% after cemented/hybrid vs. 1.5% after cementless THA (p < 0.001) and the risk of dislocations was 1.2% after cemented/hybrid THA vs. 1.8% after cementless THA (p = 0.04).Interpretation - The higher risk of PE after cemented/hybrid THA and higher risk of periprosthetic femoral fractures and dislocations after cementless THA highlights that both medically and surgically complications are related to fixation technique and have to be considered.

The role of bone cement for the development of intraoperative hypotension and hypoxia and its impact on mortality in hemiarthroplasty for femoral neck fractures

Background and purpose - The bone cement implantation syndrome characterized by hypotension and/or hypoxia is a well-known complication in cemented arthroplasty. We studied the incidence of hypotension and/or hypoxia in patients undergoing cemented or uncemented hemiarthroplasty for femoral neck fractures and evaluated whether bone cement was an independent risk factor for postoperative mortality.Patients and methods - In this retrospective cohort study, 1,095 patients from 2 hospitals undergoing hemiarthroplasty with (n = 986) and without (n = 109) bone cementation were included. Pre-, intra-, and postoperative data were obtained from electronic medical records. Each patient was classified for grade of hypotension and hypoxia during and after prosthesis insertion according to Donaldson's criteria (Grade 1, 2, 3). After adjustments for confounders, the hazard ratio (HR) for the use of bone cement on 1-year mortality was assessed.Results - The incidence of hypoxia and/or hypotension was higher in the cemented (28%) compared with the uncemented group (17%) (p = 0.003). The incidence of severe hypotension/hypoxia (grade 2 or 3) was 6.9% in the cemented, but not observed in the uncemented group. The use of bone cement was an independent risk factor for 1-year mortality (HR 1.9, 95% CI 1.3-2.7), when adjusted for confounders.Interpretation - The use of bone cement in hemiarthroplasty for femoral neck fractures increases the incidence of intraoperative hypoxia and/or hypotension and is an independent risk factor for postoperative 1-year mortality. Efforts should be made to identify patients at risk for BCIS and alternative strategies for the management of these patients should be considered.

[Progress on reconstruction of proximal femur in the hemiarthroplasty for intertrochanteric fracture with distal fixated long stem]

OBJECTIVE

To summarize the application of distal fixated long stem in the treatment of intertrochanteric fracture (ITF) in the sequence of proximal femoral reconstruction, fixation materials, and other details after operation, in order to improve doctor's attention to the reconstruction of the proximal femur and reduce complications.

METHODS

The related literature about the application of distal fixated long stem in the treatment of ITF was extensively reviewed, summarized, and analyzed.

RESULTS

The sequence of reconstruction is divided into fracture reconstruction priority and prosthesis reconstruction priority. The former is mainly to provide an anatomical reference for the placement of joint prostheses, the latter is mainly to provide support for fracture fixation. The distal fixated cement long stem and cementless long stem have their own characteristics, and materials of reconstruction are used in combination. There is no uniform standard for the sequence and materials of reconstruction.

CONCLUSION

Although the stability of the distal fixated long stem depends on the distal femur, the accurate reconstruction of the proximal femur is still worthy of attention.

On-Table and Short-Term Mortality: A Single-Institution Experience With Cementing All Hip Arthroplasties for Neck of Femur Fractures

BACKGROUND

To review on-table, day 0, day 1, day 7, and day 30 mortality after hemiarthroplasty or total hip arthroplasty (THA) using cemented femoral stems for femoral neck fractures in order to evaluate risk factors for perioperative and short-term mortality.

METHODS

The medical records of 751 consecutive cases with neck of femur fractures who underwent hemiarthroplasty (n = 602) or THA (n = 149) with cemented stems between January 2011 and December 2016 were retrospectively reviewed from a prospectively gathered database. The primary outcome measures were on-table, day 0, day 1, day 7, and day 30 mortality. Univariate and multivariate analyses were performed in order to identify various contributing patient and surgical variables.

RESULTS

There were 2 on-table deaths (0.27%): one patient had a cardiorespiratory arrest at the time of inserting the femoral stem and the other had a cardiorespiratory arrest at the end of wound closure some 20 minutes after cementing. There were 3 further day 0 deaths meaning the day 0 mortality rate was 0.67% (5/751). All 5 patients were older than 80 years and had an American Society of Anesthesiologists grade 3 or more. The 1-day, 7-day, and 30-day mortality rates were 0.93% (7 patients), 2.7% (20 patients), and 6.8% (51 patients), respectively. There is significantly higher 30-day mortality risk associated with increasing American Society of Anesthesiologists grade (P < .001) when adjusted for age, gender, and type of surgery (hemiarthroplasty compared with THA).

CONCLUSION

In our neck of femur fracture patients who were operated with cemented stems, 7-day and 30-day mortality rates were 2.7% and 6.8%, respectively. Cemented stems should be used with caution in elderly hip fracture patients with multiple comorbidities who are at high risk of perioperative mortality.

Surgical Treatment of Femoral Neck Fractures: A Brief Review

Hip fracture is a cause for concern in the geriatric population. It is one of the leading causes of traumatic injury in this demographic and correlates to a higher risk of all-cause morbidity and mortality. The Garden classification of femoral neck fractures (FNF) dictates treatment via internal fixation or hip replacement, including hemiarthroplasty or total hip arthroplasty. This review summarizes existing literature that has explored the difference in outcomes between internal fixation, hemiarthroplasty, and total hip arthroplasty for nondisplaced and displaced FNF in the geriatric population, and more specifically highlights the risks and benefits of a cemented vs. uncemented approach to hemiarthroplasty.

High strength brushite bioceramics obtained by selective regulation of crystal growth with chiral biomolecules

Chirality seems to play a key role in mineralization. Indeed, in biominerals, the biomolecules that guide the formation and organization of inorganic crystals and help construct materials with exceptional mechanical properties, are homochiral. Here, we show that addition of homochiral l-(+)-tartaric acid improved the mechanical properties of brushite bioceramics by decreasing their crystal size, following the classic Hall-Petch strengthening effect; d-(-)-tartaric acid had the opposite effect. Adding l-(+)-Tar increased both the compressive strength (26 MPa) and the fracture toughness (0.3 MPa m^1/2) of brushite bioceramics, by 33% and 62%, respectively, compared to brushite bioceramics without additives. In addition, l-(+)-tartaric acid enabled the fabrication of cements with high powder-to-liquid ratios, reaching a compressive strength and fracture toughness as high as 32.2 MPa and 0.6 MPa m^1/2, respectively, approximately 62% and 268% higher than that of brushite bioceramics prepared without additives, respectively. Characterization of brushite crystals from the macro- to the atomic-level revealed that this regulation is attributable to a stereochemical matching between l-(+)-tartaric acid and the chiral steps of brushite crystals, which results in inhibition of brushite crystallization. These findings provide insight into understanding the role of chirality in mineralization, and how to control the crystallographic structure of bioceramics to achieve high-performance mechanical properties. STATEMENT OF SIGNIFICANCE: Calcium-phosphate cements are promising bone repair materials. However, their suboptimal mechanical properties limit their clinical use. Natural biominerals have remarkable mechanical properties that are the result of controlled size, shape and organization of their inorganic crystals. This is achieved by biomineralization proteins that are homochiral, composed of l- amino acids. Despite the importance of chiral l-biomolecules in biominerals, using homochiral molecules to fabricate bone cements has not been studied yet. In this study, we showed that homochiral l-(+)-tartaric acid can regulate the crystal structure and improve the mechanical properties of a calcium-phosphate cement. Hence, these findings open the door for a new way of designing strong bone cement and highlight the importance of chirality in bioceramics.

Developments in Antibiotic-Eluting Scaffolds for the Treatment of Osteomyelitis

Osteomyelitis is a devastating disease caused by the infection of bone tissue and is associated with significant morbidity and mortality. It is treated with antibiotic therapy and surgical debridement. A high dose of systemic antibiotics is often required due to poor bone penetration and this is often associated with unacceptable side-effects. To overcome this, local, implantable antibiotic carriers such as polymethyl methacrylate have been developed. However, this is a non-biodegradable material that requires a second surgery to be removed. Attention has therefore shifted to new antibiotic-eluting scaffolds which can be created with a range of unique properties. The purpose of this review is to assess the level of evidence that exists for these novel local treatments. Although this field is still developing, these strategies seem promising and provide hope for the future treatment of chronic osteomyelitis.

Association Between Uncemented vs Cemented Hemiarthroplasty and Revision Surgery Among Patients With Hip Fracture

IMPORTANCE

Consensus guidelines and systematic reviews have suggested that cemented fixation is more effective than uncemented fixation in hemiarthroplasty for displaced femoral neck fractures. Given that these recommendations are based on research performed outside the United States, it is uncertain whether these findings also reflect the US experience.

OBJECTIVE

To compare the outcomes associated with cemented vs uncemented hemiarthroplasty in a large US integrated health care system.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of 12 491 patients aged 60 years and older who underwent hemiarthroplasty treatment of a hip fracture between 2009 and 2017 at 1 of the 36 hospitals owned by Kaiser Permanente, a large US health maintenance organization. Patients were followed up until membership termination, death, or the study end date of December 31, 2017.

EXPOSURES

Hemiarthroplasty (prosthetic replacement of the femoral head) fixation via bony growth into a porous-coated implant (uncemented) or with cement.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was aseptic revision, defined as any reoperation performed after the index procedure involving exchange of the existing implant for reasons other than infection. Secondary outcomes were mortality (in-hospital, postdischarge, and overall), 90-day medical complications, 90-day emergency department visits, and 90-day unplanned readmissions.

RESULTS

Among 12 491 patients in the study cohort who underwent hemiarthroplasty for hip fracture (median age, 83 years; 8660 women [69.3%]), 6042 (48.4%) had undergone uncemented fixation and 6449 (51.6%) had undergone cemented fixation, and the median length of follow-up was 3.8 years. In the multivariable regression analysis controlling for confounders, uncemented fixation was associated with a significantly higher risk of aseptic revision (cumulative incidence at 1 year after operation, 3.0% vs 1.3%; absolute difference, 1.7% [95% CI, 1.1%-2.2%]; hazard ratio [HR], 1.77 [95% CI, 1.43-2.19]; P < .001). Of the 6 prespecified secondary end points, none showed a statistically significant difference between groups, including in-hospital mortality (1.7% for uncemented fixation vs 2.0% for cemented fixation; HR, 0.94 [95% CI, 0.73-1.21]; P = .61) and overall mortality (cumulative incidence at 1 year after operation: 20.0% for uncemented fixation vs 22.8% for cemented fixation; HR, 0.95 [95% CI, 0.90-1.01]; P = .08).

CONCLUSIONS AND RELEVANCE

Among patients with hip fracture treated with hemiarthroplasty in a large US integrated health care system, uncemented fixation, compared with cemented fixation, was associated with a statistically significantly higher risk of aseptic revision. These findings suggest that US surgeons should consider cemented fixation in the hemiarthroplasty treatment of displaced femoral neck fractures in the absence of contraindications.

Cemented Proximal Femoral Replacement for the Management of Non-Neoplastic Conditions: A Versatile Implant but Not Without Its Risks

BACKGROUND

The demand for revision arthroplasty continues to grow. Proximal femoral bone loss poses a significant challenge to surgeons and proximal femoral replacements (PFRs) are one option to address this problem. The aim of our study is to assess the reoperation, complication, and mortality rates following PFR for treatment of non-neoplastic conditions.

METHODS

A retrospective observational study was conducted of a consecutive group of patients treated with a PFR for non-neoplastic conditions between 2010 and 2018. Mortality was confirmed using the Irish national death events publication service.

RESULTS

Over the 8-year study period, 79 PFRs in 78 patients were performed. Mean age of patients was 78.3 years (standard deviation 11.9), of which 37.2% were male. Periprosthetic fracture was the most common indication for PFR (63.3%). The 30-day mortality rate was 7.6% (6 patients), of which bone cement implantation syndrome occurred in 4 patients. One-year mortality was 12.7%. Complications occurred in 22.8%.

CONCLUSION

A cemented PFR is a versatile prosthesis in the armamentarium of a revision arthroplasty surgeon that allows immediate full weight-bearing. However, it may appropriately be considered a last resort procedure that poses specific risks that must be explained to patients and family. We present the short-term outcomes on one of the largest series of PFR to date.

Cemented versus uncemented hemi-arthroplasty for femoral neck fractures in elderly patients: A systematic review and meta-analysis of randomized controlled trials

AIM

To compare the efficacy and safety of cemented and uncemented hemiarthroplasty in elderly patients with femoral neck fracture.

MATERIALS AND METHODS

We searched PubMed, EMBASE, and Cochrane Library databases for published randomized clinical trials comparing cemented hemiarthroplasty with uncemented hemiarthroplasty in elderly patients with a femoral neck fracture. The search was not limited to language, time, or other factors. The quality of each study was assessed using the revised Jadad scale. Two researchers independently extracted data from all selected studies, including the following base line data: study period, fracture stage, number of patients, male female ratio, average age, and per-protocol (PP) or intent-to-treat (ITT), and the interest outcomes: the mortality at 12 months, operative time, hospital stay, common complications, prosthetic-related complications, blood loss and Harris Hip Score (HHS). Fixed-effects or random-effects models with mean differences and odds ratios were used to pool the continuous and dichotomous variables to determine heterogeneity of the included studies.

RESULTS

A total of 8 studies involving 1577 hips (782 uncemented and 795 cemented) were included in this meta-analysis. The meta-analysis is indicated that the operation time of cemented hemiarthroplasty was longer than uncemented hemiarthroplasty and there was statistical significance between two groups (OR = -7.30, 95%CI, -13.13, -1.46; P = .01). However, there was no significant difference between the two methods of fixation in mortality at 12 months (OR = 1.22, 95%CI, 0.94-1.59; P = .14), hospital stay (OR = 0.26, 95%CI, -0.41, 0.93; P = .44), blood loss (OR = -17.94, 95%CI, -65.83, 29.95; P = .46), and HHS score. There were significant differences in the common complications of pulmonary embolism between the two groups, but there were no differences in the other five common complications. The results showed that uncemented hemiarthroplasty could reduce the incidence of pulmonary embolism after operation. Moreover, the outcomes of prosthetic-related complications showed that there were significant differences between the two groups in periprosthetic fracture (OR = 8.32, 95%CI, 3.85-17.98; P < .00001) and prosthetic subsidence and loosening (OR = 5.33, 95%CI, 2.18-13.00; P = .0002).

CONCLUSIONS

Our study shows that uncemented prosthesis can shorten the operation time and reduce the incidence of pulmonary embolism, but it does not reduce mortality, blood loss, and hospital stay. Most importantly, the incidence of prosthetic-related complications was higher in uncemented patients.

Cemented or Uncemented Hemiarthroplasty for Femoral Neck Fracture? Data from the Norwegian Hip Fracture Register

BACKGROUND

A displaced femoral neck fracture in patients older than 70 years is a serious injury that influences the patient's quality of life and can cause serious complications or death. Previous national guidelines and a Cochrane review have recommended cemented fixation for arthroplasty to treat hip fractures in older patients, but data suggest that these guidelines are inconsistently followed in many parts of the world; the effects of that must be better characterized.

QUESTIONS/PURPOSES

The purpose of this study was to evaluate a large group of patients in the Norwegian Hip Fracture Register to investigate whether the fixation method in hemiarthroplasty is associated with (1) the risk of reoperation; (2) the mortality rate; and (3) patient-reported outcome measures (PROMs).

METHODS

Longitudinally maintained registry data from the Norwegian Hip Fracture Register with high completeness (93%) and near 100% followup of deaths were used for this report. From 2005 to 2017, 104,993 hip fractures were registered in the Norwegian Hip Fracture Register. Fractures other than intracapsular femoral neck fractures and operative methods other than bipolar hemiarthroplasty, such as osteosynthesis or THA, were excluded. The selection bias risk on using cemented or uncemented hemiarthroplasty is small in Norway because the decision is usually regulated by tender processes at each hospital and not by surgeon. A total of 7539 uncemented hemiarthroplasties (70% women, mean age, 84 years [SD 6] years) and 22,639 cemented hemiarthroplasties (72% women, mean age, 84 years [SD 6] years) were eligible for analysis. Hazard risk ratio (HRR) on reoperation and mortality was calculated in a Cox regression model adjusted for age, sex, comorbidities (according to the American Society of Anesthesiologists classification), cognitive function, surgical approach, and duration of surgery. At 12 months postoperatively, 65% of patients answered questionnaires regarding pain and quality of life, the results of which were compared between the fixation groups.

RESULTS

A higher overall risk of reoperation for any reason was found after uncemented hemiarthroplasty (HRR, 1.5; 95% CI, 1.4-1.7; p < 0.001) than after cemented hemiarthroplasty. When assessing reoperations for specific causes, higher risks of reoperation because of periprosthetic fracture (HRR, 5.1; 95% CI, 3.5-7.5; p < 0.001) and infection (HRR, 1.2; 95% CI, 1.0-1.5; p = 0.037) were found for uncemented hemiarthroplasty than for cemented procedures. No differences were found in the overall mortality rate after 1 year (HRR, 1.0; 95% CI, 0.9-1.0; p = 0.12). Hemiarthroplasty fixation type was not associated with differences in patients' pain (19 versus 20 for uncemented and cemented hemiarthroplasties respectively, p = 0.052) or quality of life (EuroQol [EQ]-VAS score 64 versus 64, p = 0.43, EQ5D index score 0.64 versus 0.63, p = 0.061) 1 year after surgery.

CONCLUSIONS

Our study found that the fixation method was not associated with differences in pain, quality of life, or the 1-year mortality rate after hemiarthroplasty. Uncemented hemiarthroplasties should not be used when treating elderly patients with hip fractures because there is an increased reoperation risk.Level of Evidence Level III, therapeutic study.

Review article: Patient characteristics that act as risk factors for intraoperative complications in hip, knee, and shoulder arthroplasties

The number of annual THA's, TKA's, and TSA's is set to increase significantly by the year 2030, making it imperative to understand the risks for negative outcomes in these procedures. While research has studied the patient risk factors for perioperative and postoperative complications, there has been relatively little research for intraoperative complications. After a thorough literature review, the most supported finding was that patients with a BMI >30 had significantly more intraoperative blood loss than those with a BMI <30. All other relationships between patient risk factors and intraoperative complications of interest were inadequately studied.

Perioperative, short-, and long-term mortality related to fixation in primary total hip arthroplasty: a study on 79,557 patients in the -Norwegian Arthroplasty Register

Background and purpose - There are reports on perioperative deaths in cemented total hip arthroplasty (THA), and THA revisions are associated with increased mortality. We compared perioperative (intraoperatively or within 3 days of surgery), short-term and long-term mortality after all-cemented, all-uncemented, reverse hybrid (cemented cup and uncemented stem), and hybrid (uncemented cup and cemented stem) THAs.Patients and methods - We studied THA patients in the Norwegian Arthroplasty Register from 2005 to 2018, and performed Kaplan-Meier and Cox survival analyses with time of death as end-point. Mortality was calculated for all patients, and in 3 defined risk groups: high-risk patients (age ≥ 75 years and ASA > 2), intermediate-risk patients (age ≥ 75 years or ASA > 2), low-risk patients (age < 75 years and ASA ≤ 2). We also calculated mortality in patients with THA due to a hip fracture, and in patients with commonly used, contemporary, well-documented THAs. Adjustement was made for age, sex, ASA class, indication, and year of surgery.Results - Among the 79,557 included primary THA patients, 11,693 (15%) died after 5.8 (0-14) years' follow-up. Perioperative deaths were rare (30/10⁵) and found in all fixation groups. Perioperative mortality after THA was 4/10⁵ in low-risk patients, 34/10⁵ in intermediate-risk patients, and 190/10⁵ in high-risk patients. High-risk patients had 9 (CI 1.3-58) times adjusted risk of perioperative death compared with low-risk patients. All 4 modes of fixation had similar adjusted 3-day, 30-day, 90-day, 3-30 day, 30-90 day, 90-day-10-year, and 10-year mortality risk.Interpretation - Perioperative, short-term, and long-term mortality after primary THA were similar, regardless of fixation type. Perioperative deaths were rare and associated with age and comorbidity, and not type of fixation.

Cementless Bipolar Hemiarthroplasty for Low-energy Intracapsular Proximal Femoral Fracture in Elderly East-Asian Patients: A Longitudinal 10-year Follow-up Study

Purpose

Short-term outcomes following cemented and cementless hemiarthroplasties (HAs) are reported to be comparable, however, long-term outcomes of cementless HA—especially among Asian patients—is limited. We aimed to assess long-term outcomes in elderly East-Asian patients with intracapsular proximal femoral fractures treated with cementless HA.

Materials and Methods

We enrolled 135 patients treated with cementless HA who met our inclusion criteria. We documented bone/implant-related complications (e.g., incidences of revision hip surgery, femoral stem subsidence, dislocation, intraoperative and postoperative periprosthetic fractures, contralateral hip fractures). We included those patients who are still alive 10 years after the index surgery in the final functional analysis of the existence of pain, ambulatory status, and residential status.

Results

The mean age at injury was 78.3 years (range: 60–85 years). At the 10-year follow-up, 26 of the original patients (19.3%) had survived. During follow-up, revision hip surgery was conducted in two patients (1.5%). We recorded the incidence of intraoperative fractures, postoperative periprosthetic fractures, and contralateral fractures in two (1.5%), eight (5.9%), and six patients (4.4%), respectively. Among the 10-year survivors, six patients (23.1% of the survivors) complained of groin pain, but generally reported the pain to be tolerable.

Conclusion

Among elderly East-Asian patients, the incidence of revision surgery after cementless HA may be lower than that in their European counterparts, whereas the incidence of periprosthetic fractures can still be considerably higher. For patients undergoing cementless HA, prevention of such secondary fractures is of critical importance.

Inhaled prostacyclin for the prevention of increased pulmonary vascular resistance in cemented hip hemiarthroplasty-A randomised trial

BACKGROUND

Bone cementation may cause pulmonary vasoconstriction and ventilation/perfusion abnormalities in patients undergoing cemented hip hemiarthroplasty. In this randomised trial, we tested the hypothesis that intra-operative inhalation of prostacyclin could attenuate the increase in pulmonary vascular resistance index (PVRI, primary endpoint) when compared to inhaled saline in this group of patients.

METHODS

Twenty-two patients with displaced femoral neck fractures were allocated to receive inhaled aerosolised prostacyclin (20 ng/kg/min) (n = 11) or inhaled saline (NaCl, 9 mg/mL) (n = 11). All patients received total intravenous anaesthesia and were catheterised with radial and pulmonary artery fast response thermodilution catheters, for measurements of arterial and pulmonary arterial pressures, cardiac output, right ventricular ejection fraction and effective pulmonary arterial elastance. Haemodynamic measurements were performed after induction of anaesthesia, during surgery before and immediately after bone cementation and prosthesis insertion, 10 and 20 min after insertion and during skin closure.

RESULTS

During the surgical procedure, PVRI increased both in the saline (44%, P < 0.001) and the prostacyclin (36%, P = 0.019) groups, with a less pronounced increase in the prostacyclin group (P = 0.031). Effective pulmonary arterial elastance increased both in the saline (44%, P < 0.001) and the prostacyclin groups (29%, P = 0.032), with a trend for a less pronounced increase in the prostacyclin group (P = 0.084). Right ventricular ejection fraction decreased significantly in both groups with no difference between the groups.

CONCLUSION

Inhalation of prostacyclin attenuates the increase in pulmonary vascular resistance in patients undergoing cemented hip hemiarthroplasty and could potentially attenuate/prevent haemodynamic instability induced by an increase in right ventricular afterload seen in this procedure.

Bone cement leaking into iliac vein during artificial femoral head replacement: A case report

RATIONALE

Leakage of bone cement from femoral medullary cavity is a rare complication after hip arthroplasty, and there is no report on the leaked bone cement entering into iliac vessels.

PATIENT CONCERNS

An 89-year-old woman presented with a fracture in the right femoral neck. She had well-fixed right femoral head replacement after careful preoperative examinations, and no adverse reactions appeared. She was able to get off bed to walk at the 2nd day after surgery.

DIAGNOSES

Postoperative radiograph showed leakage of bone cement into the joint through femoral medullary cavity entering into iliac vessels, but the patient complained no discomforts. She received a treatment with low-molecular weight heparin and rivaroxaban.

OUTCOMES

The patient was able to walk with normal gait, without swelling in both lower extremities and discomfort in the hip. There was no other complication concerning intravascular foreign bodies.

LESSONS

This case calls into the phenomenon of leakage of injected bone cement in femoral head replacement regardless of complete and nonfractured femur, which may be into the lower limb and pelvic veins, given that, dangerous consequences will not occur.

Does time from fracture to surgery affect mortality and intraoperative medical complications for hip fracture patients? An observational study of 73 557 patients reported to the Norwegian Hip Fracture Register

AIMS

The aim of this study was to investigate mortality and risk of intraoperative medical complications depending on delay to hip fracture surgery by using data from the Norwegian Hip Fracture Register (NHFR) and the Norwegian Patient Registry (NPR).

PATIENTS AND METHODS

A total of 83 727 hip fractures were reported to the NHFR between 2008 and 2017. Pathological fractures, unspecified type of fractures or treatment, patients less than 50 years of age, unknown delay to surgery, and delays to surgery of greater than four days were excluded. We studied total delay (fracture to surgery, n = 38 754) and hospital delay (admission to surgery, n = 73 557). Cox regression analyses were performed to calculate relative risks (RRs) adjusted for sex, age, American Society of Anesthesiologists (ASA) classification, type of surgery, and type of fracture. Odds ratio (OR) was calculated for intraoperative medical complications. We compared delays of 12 hours or less, 13 to 24 hours, 25 to 36 hours, 37 to 48 hours, and more than 48 hours.

RESULTS

Mortality remained unchanged when total delay was less than 48 hours. Total delay exceeding 48 hours was associated with increased three-day mortality (RR 1.69, 95% confidence interval (CI) 1.23 to 2.34; p = 0.001) and one-year mortality (RR 1.06, 95% CI 1.04 to 1.22; p = 0.003). More intraoperative medical complications were reported when hospital delay exceeded 24 hours.

CONCLUSION

Hospitals should operate on patients within 48 hours after fracture to reduce mortality and intraoperative complications. Cite this article: Bone Joint J 2019;101-B:1129-1137.

Nanoparticle-based model of anti-inflammatory drug releasing LbL coatings for uncemented prosthesis aseptic loosening prevention

Introduction

The only treatment for aseptic loosening is the replacement of the prosthesis through revision surgery. A preventive approach, achieved through anti-inflammatory drugs released from the device, has shown to be a viable strategy; however, the performance of these devices is not yet satisfactory thus further improvements are necessary.

Methods

We used titanium nanoparticles as a model for implant surfaces and developed a coating containing dexamethasone (DEX) using layer-by-layer deposition.

Results

The amount of deposited drug depended on the number of layers and the release was sustained for months. The efficiency of the released DEX in reducing inflammation markers (tumor necrosis factor alpha and IL-6) produced by human monocytes and macrophages was similar to the pure drug at the same concentration without negative impacts on the viability and morphology of these cells.

Conclusion

These coatings were not inferior to medical grade titanium (the standard material used in uncemented devices) regarding their ability to sustain osteoblasts and fibroblasts growth.

Occurrence, risk factors, and outcomes of bone cement implantation syndrome after hemi and total hip arthroplasty in cancer patients

BACKGROUND AND OBJECTIVES

Patients undergoing cement fixation for hip arthroplasty are at increased risk of developing bone cement implantation syndrome (BCIS). We sought to determine: what is the occurrence of BCIS in patients with cancer after hip arthroplasty? What are the risk factors in patients with cancer for the development of this syndrome? What is the outcome for patients with cancer having BCIS?

METHODS

We identified 374 patients with cancer who underwent cemented hip arthroplasty between 2010 and 2014. Patient characteristics, operative variables, and outcomes were collected.

RESULTS

BCIS occurred in 279 (75%) patients. A total of 353 (94%) patients had bone metastases and 179 (48%) patients had lung metastases at the time of surgery. Age greater than 60 (hazard ratio [HR] 2.09, P = .02) and the presence of lung metastases (HR 1.77, P = .019) were associated with increased risk of BCIS. Increased perioperative use of vasopressors (HR 1.72, P = .023) and increased hospital stay beyond 10 days (HR 2.67, P = .003) was associated with BCIS.

CONCLUSIONS

BCIS is a frequent clinical event in patients with cancer undergoing femoral cemented arthroplasty with increased risk for patients over age 60 and those with compromised lung function due to lung metastases and lung cancer. Patients who develop BCIS are more likely to require longer postoperative hospitalization. Careful preoperative assessment and intraoperative communication are crucial steps to reduce the consequences of BCIS.

Megaprosthesis in distal femur nonunions in elderly patients-experience from twenty four cases

Purpose of the study

To evaluate the outcomes and complications using cemented megaprosthesis in elderly patients with distal femur nonunions (DFN).

Materials and methods

Between 2012 and 2016, 24 patients of DFN with an average age of 71.8 years (66–83) and an average 1.9(1–3) prior surgery was managed with distal femur replacement using cemented modular endoprosthesis. Outcomes were analysed on the following criteria: implant status, complications, knee range of motion, Knee Society Score (KSS) and Musculoskeletal Tumor Society (MSTS) score.

Results

All patients were extremely satisfied with their outcomes. At an average 22.1 months (10–43) follow-up, patients had an average 69.5° (40°-110°) knee flexion, an average KSS of 75.7 (63–88) and an average MSTS score of 19.3 (17–25). Four patients died at an average 21.3 months after surgery due to causes unrelated to the fracture. One patient (4.1%) had implant-related complication; deep infection which required debridement and intravenous antibiotics. There were no late amputations or peri-operative deaths and no patient had aseptic loosening of components.

Conclusion

By permitting immediate full weight-bearing ambulation and with most patients returning to an acceptable functional status, cemented megaprosthesis is a viable and useful single-stage management option in elderly patients with DFN.

Biomechanical behaviours of the bone-implant interface: a review

In recent decades, cementless implants have been widely used in clinical practice to replace missing organs, to replace damaged or missing bone tissue or to restore joint functionality. However, there remain risks of failure which may have dramatic consequences. The success of an implant depends on its stability, which is determined by the biomechanical properties of the bone-implant interface (BII). The aim of this review article is to provide more insight on the current state of the art concerning the evolution of the biomechanical properties of the BII as a function of the implant's environment. The main characteristics of the BII and the determinants of implant stability are first introduced. Then, the different mechanical methods that have been employed to derive the macroscopic properties of the BII will be described. The experimental multi-modality approaches used to determine the microscopic biomechanical properties of periprosthetic newly formed bone tissue are also reviewed. Eventually, the influence of the implant's properties, in terms of both surface properties and biomaterials, is investigated. A better understanding of the phenomena occurring at the BII will lead to (i) medical devices that help surgeons to determine an implant's stability and (ii) an improvement in the quality of implants.

Perioperative morbidity in total knee arthroplasty

Introduction

As the life expectancy and weight of patients are increasing, more old and obese patients are undergoing total knee arthroplasty (TKA). TKA may lead to several perioperative complications. These include anesthesia-related risks, exacerbation of comorbid medical issues and complications of surgical procedure. We have no studies reporting medical complications following TKA among our population. This study aimed to evaluate perioperative complications of TKA and to identify the related risk factors.

Methods

It was a monocentric retrospective including 410 observations in the local TKA registry. Data of patients operated for primary unilateral TKA during the period from January 2014 to December 2017 were reviewed. All patients had standardized protocols of anesthesia and post operative care for three days following surgery. Multivariate logistic regression was used to identify the predicting factors for complications.

Results

Incidence of perioperative complications was 37.1%. The most frequent were per operative hypotension (14.1%) and postoperative desaturation (21.7%, including pulmonary embolism in 2.4%). Multivariate logistic regression analysis identified: age ≥ 65 years (OR=1.9; p=0.006), respiratory diseases (OR=1.8; p=0.042) and general anesthesia (OR=2.8; p=0.009) as significant risk factors for any complications. Loss of autonomy (OR=4.8; p <0.001) and general anesthesia (OR=2.6; p=0.03) were significant risk factors for hypotension. Age ≥ 65 years (OR=2.6;p<0.001), female gender (OR=4.3;p=0.006) and respiratory diseases(OR=1.9;p=0.02) were associated with postoperative desaturation.

Conclusion

This study highlighted hemodynamic and respiratory complications as the most common early complications in TKA. Age ≥ 65years, general anesthesia and respiratory diseases were significant risk factors.

Perioperative mortality secondary to a pulmonary embolism during a surgical implantation of the Endo-Exo-Prosthesis: a case report

We report on a 53‐year‐old female patient who suffered a perioperative death secondary to a pulmonary embolism (PE) during an implantation of Endo‐Exo‐Prosthesis. This is a retrospective review of medical case for a patient who had a previous above‐the‐knee amputation secondary to a failed previous arthroplasty surgery. Our planned surgery was a stage 1 implantation of an Endo‐Exo‐Prosthesis, and it was performed under general anaesthesia. After 25 min from starting the surgical procedure, the patient sustained a cardiac arrest, and despite an active cardiopulmonary resuscitation for 50 min, the patient did not recover, the ventilator machine was stopped later on, and the patient was declared deceased at that stage. Fatal intraoperative PE is a rare but significant complication during orthopaedic procedures. There are few reports of similar events but include mainly trauma patients with fractured neck of femur. Endo‐Exo‐Prosthesis is a relatively newly evolved procedure in a unique group of patients. To our knowledge, this is the first case report of such complication during Endo‐Exo‐Prosthesis implantation. Patient and surgeon should be aware of it, and additional preventive measures like preoperative scoring systems and in special cases using inferior vena cava filter should be considered in patients with high risk of developing venous thromboembolism.

Uncemented Reverse Total Shoulder Arthroplasty as Initial Treatment for Comminuted Proximal Humerus Fractures

OBJECTIVES

To determine whether uncemented implants would provide similar outcomes while avoiding the complications associated with cement in the treatment of elderly patients with proximal humerus fractures (PHFs) with primary reverse total shoulder arthroplasty (RTSA).

DESIGN

Case series.

SETTING

A single Level I trauma center.

PATIENTS/PARTICIPANTS

A prospectively obtained cohort of 30 patients who underwent uncemented RTSA as initial treatment for a comminuted PHF: 4 male, 26 female; average age 71 ± 11 years.

INTERVENTION

Uncemented RTSA.

MAIN OUTCOME MEASURES

(1) Radiographic analysis, (2) postoperative clinical range of motion, and (3) functional outcome scores: the American Shoulder and Elbow Surgeons Shoulder score and the Simple Shoulder Test score.

RESULTS

Radiographic analysis showed 97% achieved stable humeral stem fixation and 70% had healing of the tuberosities in anatomical position. Average range of motion was 130 ± 31 degrees of forward flexion, 32 ± 18 degrees of external rotation, and internal rotation to the midlumbar spine. Average American Shoulder and Elbow Surgeons Shoulder score was 82.0 ± 13.5 (with an average pain rating of 0.8 ± 1.3), and average Simple Shoulder Test score was 69.4% ± 19.1%.

CONCLUSIONS

Our data show that treatment of comminuted PHFs in elderly patients with uncemented RTSA can consistently produce good clinical outcomes with a low rate of complications and suggest that cement may not be necessary for RTSA in the trauma setting.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cementing does not increase the immediate postoperative risk of death after total hip arthroplasty or hemiarthroplasty: a hospital-based study of 10,677 patients

Background and purpose - It has been suggested that cemented arthroplasty is associated with increased peri- and postoperative mortality due to bone cement implanting syndrome, especially in fracture surgery. We investigated such an association in elective total hip arthroplasty (THA) patients and hemiarthroplasty (HA) patients treated for femoral neck fracture. Patients and methods - All 10,677 patients receiving elective THA or HA for fracture in our hospital between 2004 and 2015 were identified. Mortality rates for cemented and uncemented THA and HA were compared at different times postoperatively using logistic regression analysis. Analysis was adjusted for age, sex, ASA class, and year of surgery. Results - Adjusted 10- and 30-day mortality after cemented THA was comparable to that of the uncemented THA (OR 1.7; 95% CI 0.3-8.7 and OR 1.6; CI 0.7-3.6, respectively). There was no statistically significant difference in the adjusted 2-day mortality in the cemented HA group when compared with the uncemented group. However, in a subgroup analyses of ASA-class IV HA patients there was a difference, statistically not significant, during the first 2 days postoperatively in the cemented HA group compared with the uncemented HA group (OR 2.1; CI 0.9-4.7). Interpretation - Cementing may still be a safe option in both elective and hip fracture arthroplasty. Excess mortality of cemented THA and HA in the longer term is comorbidity related, not due to bone cement implantation syndrome. However, in the most fragile HA patient group caution is needed at the moment of cementing.

Contemporary Management of Appendicular Skeletal Metastasis by Primary Tumor Type

Skeletal metastases exert a profound effect on patients and society, and will be encountered by most orthopedic surgeons. Once a primary malignancy is diagnosed, multidisciplinary management should focus on maximizing the quality of life while minimizing disease- and treatment-related morbidity. This may be best achieved with discerning attention to the unique characteristics of primary cancer types, including pathologic fracture healing rates, longevity, and efficacy of adjuvant therapies. Some lesions may respond well to nonsurgical measures, whereas others may require surgery. A single surgical intervention should allow immediate unrestricted activity and outlive the patient. In certain scenarios, a therapeutic benefit may be provided by excision with a curative intent. In these scenarios, or when endoprosthetic reconstruction is necessary, patients may be best referred to an orthopedic oncologist.

Pulmonary haemodynamics and right ventricular function in cemented vs uncemented total hip arthroplasty-A randomized trial

BACKGROUND

Bone cement implantation syndrome (BCIS) is a feared complication in orthopaedic surgery with a huge impact on post-operative morbidity. In this randomized trial, we evaluated the effects of bone cement on pulmonary and systemic haemodynamics in patients receiving either cemented or uncemented hip arthroplasty for isolated femoral neck fracture.

METHODS

Twenty-two patients were randomized to receive either cemented (n = 10) or uncemented (n = 12) total hip arthroplasty. Surgery was performed under total intravenous anaesthesia in the lateral position. All patients were catheterized with radial- and pulmonary artery catheters, for continuous measurements of mean arterial pressure (MAP), pulmonary arterial pressure (PAP), cardiac output, right ventricular (RV) end-diastolic volume (RVEDV) and RV ejection fraction (RVEF). Haemodynamic measurements and blood gas analyses were performed after induction of anaesthesia, during surgery before and immediately after bone cementation and prosthesis insertion, 10 and 20 minutes after insertion and during skin closure.

RESULTS

Pulmonary vascular resistance index (PVRI) increased during and after prosthesis insertion by 45% and 20% in the cemented and uncemented group, respectively (P < 0.005). Systolic and mean PAP increased by 18% and 17% in the cemented group, which was not seen in the uncemented group (P < 0.001). There was a trend for a more pronounced fall in RVEF in the cemented group, while there were no differences in cardiac output or stroke volume between groups.

CONCLUSION

The use of bone cement in total hip arthroplasty increases pulmonary vascular resistance and the afterload of the RV with potentially negative effects on RV performance.

Early postoperative mortality similar between cemented and uncemented hip arthroplasty: a register study based on Finnish national data

Background and purpose - Implant survival of cemented total hip arthroplasty (THA) in elderly patients is higher than that of uncemented THA. However, a higher mortality rate in patients undergoing cemented THA compared with uncemented or hybrid THA has been reported. We assessed whether cemented fixation increases peri- or early postoperative mortality compared with uncemented and hybrid THA. Patients and methods - Patients with osteoarthritis who received a primary THA in Finland between 1998 and 2013 were identified from the PERFECT database of the National Institute for Health and Welfare in Finland. Definitive data on fixation method and comorbidities were available for 62,221 THAs. Mortality adjusted for fixation method, sex, age group, and comorbidities among the cemented, uncemented, and hybrid THA was examined using logistic regression analysis. Reasons for cardiovascular death within 90 days since the index procedure were extracted from the national Causes of Death Statistics and assessed separately. Results - 1- to 2-day adjusted mortality after cemented THA was comparable to that of the uncemented THA group (OR 1.2; 95% CI 0.24-6.5). 3- to 10-day mortality in the cemented THA group was comparable to that in the uncemented THA group (OR 0.54; CI 0.26-1.1), and in the hybrid THA group (OR 0.64, CI 0.25-1.6). Pulmonary embolism or cardiovascular reasons as a cause of death were not over-represented in the cemented THA group. Interpretation - Early peri- and postoperative mortality in the cemented THA group was similar compared with that of the hybrid and uncemented groups.

Randomised clinical trial assessing migration of uncemented primary total hip replacement stems, with and without autologous impaction bone grafting

PURPOSE

Uncemented stems in primary total hip replacement (THR) are concerning in the elderly due to ectatic femoral canals and cortical thinning resulting in higher incidence of fracture and subsidence in this population. To obviate this concern, the authors developed a technique using autologous impaction bone grafting to achieve a better fitting femoral stem. The aim of this randomised clinical trial was to assess the efficacy of the technique.

METHODS

From 2013 to 2015, a total of 98 consecutive participants (100 primary THR procedures) were inducted into a single-institution, single-blinded, randomised clinical trial assessing, with radiostereometric analysis (RSA), the efficacy of autologous impaction bone grafting in uncemented primary THR compared with traditional uncemented primary THR technique. The primary outcome measure was femoral component migration using RSA. Secondary outcomes were post-operative proximal femoral bone density (using DEXA), hip function and quality of life using Oxford Hip Score (OHS) and Short Form-12 Health Survey (SF-12), hip pain and patient satisfaction.

RESULTS

There was no difference in femoral component stability (p > 0.5) or calcar resorption between the Graft and No Graft Groups at two years. There was also no difference in OHS, SF-12, pain or satisfaction between the Graft and No Graft Groups at two years (p > 0.39).

CONCLUSIONS

Autologous impaction bone grafting in uncemented primary THR has shown its short-term post-operative outcomes to be equivalent to standard uncemented technique, whilst offering a better fit in patients who are between femoral stem sizes.

AUSTRALIAN CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12618000652279.

Bone Cement Implantation Syndrome: Key Concepts for Perioperative Nurses

Bone cement implantation syndrome (BCIS) is a potentially fatal complication of orthopedic surgeries that use cement. The symptoms of BCIS occur primarily during femoral fracture repairs, but this complication has been reported in a wide variety of cemented procedures. Clinical presentation of this syndrome begins as a cascade with hypoxia and hypotension; if it is not reversed, it ends with right-sided heart failure and cardiac arrest. This syndrome usually occurs at cementation, prosthesis insertion, joint reduction, or tourniquet deflation, and should be treated with aggressive resuscitation and supportive care. This article provides a comprehensive explanation of bone cement, the identification and management of BCIS, and the roles of the perioperative team in the event of cardiopulmonary collapse. It includes a case study that can be used as an educational tool for simulation, mock drills, or staff meetings; it also may be used as a framework for creating policies.

Massive mass embolism detected by transesophageal echocardiography in bone cement implantation syndrome: a case report

Bone cement implantation syndrome (BCIS) is a known complication in patients undergoing cemented orthopedic surgeries; however, the etiology and pathophysiology of BCIS are not fully understood. We report the case of a patient who developed pulseless electrical activity (PEA) due to BCIS after cemented femoral head replacement. Transesophageal echocardiography (TEE) during PEA revealed a massive embolus extending from the main pulmonary artery to the inferior vena cava. Of note, this embolus disappeared completely and rapidly after return of spontaneous circulation. TEE proved to be useful in the diagnosis and management of this case of PEA.

Comparison between Colloid Preload and Coload in Bone Cement Implantation Syndrome under Spinal Anesthesia: A Randomized Controlled Trial

Background:

Bone cement implantation syndrome (BCIS) is characterized by hypoxia hypotension cardiac arrest. There is not any research that investigated the hemodynamic effects of colloid use during and before cement implantation regarding BCIS development.

Aims:

We aimed to compare the effects of colloid preloading before or coloading simultaneously at cement implantation on BCIS development and hemodynamic parameters in patients who underwent total knee arthroplasty.

Settings and Design:

This is a prospective, randomized, clinical trial with the participation of 109 patients over 60 years of age and patients physical status American Society of Anesthesiologists Classes I and II to undergo knee surgery. The patients were administered spinal anesthesia, divided into three groups.

Subjects and Methods:

The patients in Group I were infused 8 mL/kg hydroxyethyl starch (130/0.4) 20 min before the cement implantation, those in Group II were infused the same simultaneously during cement implantation. Group III was infused 8 mL/kg/h sodium chloride during the anesthesia management. Hemodynamic parameters of the patients were recorded at before and after cement implantation and once the tourniquet was removed.

Statistical Analysis Used:

The descriptive statistics were presented as the mean ± standard deviation for normally distributed variables, as the median for nonnormally distributed variables, and as the number of cases and (%) for nominal variables. Pearson's Chi-square test and Fisher's exact test were used in the analysis of categorical variables.

Results:

Compared to the control group, Groups I and II were hemodynamically more stable. The development of moderate hypoxia during cement implantation was significantly different between the study groups (P < 0.05).

Conclusions:

We suggest that avoiding intravascular volume depletion by using the colloids, particularly in elderly patients, is important for preventing from the BCIS.

Regional Cerebral Oxygen Saturation Decreases During Primary Hip Arthroplasty: An Analysis of Perioperative Regional Cerebral Oxygenation (rSO2), S100 Calcium-Binding Protein B (S100B) and Glial Fibrillary Acidic Protein (GFAP) Values. A Pilot Study

Background

The incidence of postoperative cognitive dysfunction (POCD) after major joint arthroplasty is high. In the etiology of POCD, many factors have been cited, including thromboembolic complications. The incidence of cerebral embolization after lower extremity arthroplasty may be as high as 40–60%. The potential events of cerebral embolization could lead to a decrease in the regional cerebral oxygenation (rSO₂) and increased serum levels of biochemical markers of brain damage. The objective of the study was to test whether there are any changes in the rSO₂ values and serum markers of brain damage in patients who underwent total hip arthroplasty.

Material/Methods

Fifteen patients who underwent primary hip arthroplasty under spinal anesthesia were analyzed. The rSO₂ was monitored using infrared spectroscopy. Biochemical analyses of S100 calcium-binding protein B (S100B) protein and fibrillary acidic protein (GFAP) serum concentrations were performed using immunoassay methods.

Results

The values of rSO₂ decreased during the surgery, but this was not related to mean arterial pressure variations or hemoglobin saturation. The concentration of S100B was increased compared to its preoperative values, and there were no changes in GFAP values. The changes in rSO₂ readings correlated with the biomarkers’ levels just after the surgery.

Conclusions

Our results suggest that S100B may be a more specific marker of astroglial damage in patients after primary total hip arthroplasty. The decrease in rSO₂ readings may be due to micro-thromboembolic events that occurred during the surgery. However, the results of this study are preliminary, and further studies are needed to establish its clinical efficacy.

Preoperative myocardial troponin T elevation is associated with the fracture type in patients with proximal femoral fracture

BACKGROUND AND AIMS

Cardiovascular complications are common in hip fracture patients but the role of fracture type and operative method in these is unclear. This prospective cohort study aimed to evaluate the impact of fracture- and operative characteristics on perioperative cardiovascular complications and prognosis in unselected hip fracture patients.

MATERIAL AND METHODS

During a 7-month trial registration period, a population of 197 consecutive hip fracture patients (median age 84 years) diagnosed with femoral neck or pertrochanteric fracture was formed. The exclusion criteria were patient refusal, subtrochanteric fracture, or death preoperatively. Pre- and postoperative troponin T (TnT) elevation, perioperative N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP) level, perioperative cardiovascular adverse events, and all-cause 30-day and 2- and 5-year mortalities were studied.

RESULTS

Femoral neck fracture was independently associated with preoperative myocardial injury witnessed by TnT elevation (HR 2.95, 95% confidence interval 1.21-7.19, p = 0.018). The fracture type, surgery delay, or operative method were not significantly associated with NT-proBNP levels, cardiovascular adverse event diagnoses, or prognosis. Cardiovascular adverse events were clinically diagnosed in 28 (14%) participants, and these had a higher mortality compared to participants without such diagnosis (at 30 days, 32% vs 5%; 2 years, 71% vs 31%; and 5 years, 86% vs 59%; p < 0.001).

CONCLUSION

While the femoral neck fracture independently predicts preoperative cardiovascular morbidity, the operative method does not affect perioperative cardiovascular complications or the prognosis, and it may be selected by the treating clinician based on other criteria.

A Comparative Study Between Uncemented and Hybrid Total Hip Arthroplasty in Octogenarians

BACKGROUND

The aim of this prospective cohort study is to evaluate the outcome of octogenarian patients undergoing uncemented total hip arthroplasty (THA) with a control group of similarly aged patients undergoing hybrid THA with a minimum 5-year follow-up.

METHODS

Clinical outcomes including intraoperative and postoperative complications, blood transfusion, revision rate, and mortality were recorded. Radiological analysis of preoperative and postoperative radiographs assessed bone quality, implant fixation, and any subsequent loosening.

RESULTS

One hundred forty-three patients (mean age 86.2 years) were enrolled in the study. Seventy-six patients underwent uncemented THA and 67 underwent hybrid THA. The uncemented cohort had a significantly lower intraoperative complication rate (P = .017) and also a lower transfusion rate (P = .002). Mean hospital stay (P = .27) was comparable between the 2 groups. Two patients underwent revision surgery in each cohort.

CONCLUSION

Our study demonstrates that uncemented THA is safe for the octogenarian patient and we recommend that age should not be a barrier to the choice of implant. However, intraoperative assessment of bone quality should guide surgeons to the optimum decision regarding uncemented and hybrid implants.

LEVEL OF EVIDENCE

3.

Fourteen-year experience with short cemented stems in total hip replacement

PURPOSE

The age of the population requiring total hip replacement (THR) is increasing and this may lead to a return of cemented stems. Advantages of a short cemented femoral device include preservation of metaphyseal bone, easier insertion, and easier cement removal in case of revision. The purpose of this study is to describe the rationale and assess midterm results of unique innovative short cemented double-tapered polished stem applied with contemporary cementing techniques.

METHODS

Our experience with this short cemented stem includes two different groups of elderly patients. Group 1 (prototype version of the short stem) from January 2005 to January 2008 counts 43 THR. Group 2 (final commercial version of the short stem) from January 2013 to January 2015 counts 54 THR. The average age in groups 1 and 2 was 79 and 75 respectively. Patients underwent clinical follow-up with the Harris Hip Score (HHS) and completed radiographic evaluation.

RESULTS

Thirty-one patients of group 1 had died for reasons unrelated to their THR. The surviving 9 hips have a follow-up of 11.2 years. In group 2, eight  patients died for reasons unrelated to their THR. Follow-up for the surviving 40 patients is 4.6 years. HHS improved in both groups. In 34/43 hips of group 1 and in 41/54 of group 2 we observed a Barrack grade A cement mantle. Survival with revision of the stem for aseptic loosening as the endpoint was 100%.

CONCLUSIONS

This study confirms the effectiveness of a short, polished, collarless, tapered cemented stem implanted with contemporary cementing techniques which appears as successful as the standard sized components.

Hip replacement

Total hip replacement is a frequently done and highly successful surgical intervention. The procedure is undertaken to relieve pain and improve function in individuals with advanced arthritis of the hip joint. Symptomatic osteoarthritis is the most common indication for surgery. In paper 1 of this Series, we focus on how patient factors should inform the surgical decision-making process. Substantial demands are placed upon modern implants, because patients expect to remain active for longer. We discuss the advances made in implant performance and the developments in perioperative practice that have reduced complications. Assessment of surgery outcomes should include patient-reported outcome measures and implant survival rates that are based on data from joint replacement registries. The high-profile failure of some widely used metal-on-metal prostheses has shown the shortcomings of the existing regulatory framework. We consider how proposed changes to the regulatory framework could influence safety.

Hemiarthroplasty and total hip arthroplasty in 30,830 patients with hip fractures: data from the Dutch Arthroplasty Register on revision and risk factors for revision

Background and purpose - In the Netherlands about 40% of hip fractures are treated with a hemiarthroplasty (HA) or a total hip arthroplasty (THA). Although these procedures are claimed to have fewer complications than osteosynthesis (i.e., reoperation), complications still occur. Analyses of data from national registries with adequate completeness of revision surgery are important to establish guidelines to diminish the risk for revision. We identified risk factors for revision. Patients and methods - All patients older than 50 years of age with a hip fracture treated with arthroplasty by orthopedic surgeons and registered in the (national) Dutch arthroplasty register (LROI) were included in the study. In this register, patient characteristics and surgical details were prospectively collected. Revision surgery and reasons for revision were evaluated. A proportional hazard ratio model for revision was created using competing risk analysis (with death as competing risk). Results - 1-year revision rate of HA was (cumulative incidence function [CIF] 1.6% (95% CI 1.4-1.8) and THA 2.4% (CI 2.0-2.7). Dislocation was the most common reason for revision in both groups (HA 29%, THA 41%). Male sex, age under 80 years, posterolateral approach, and uncemented stem fixation were risk factors for revision in both THA and HA. THA patients with ASA classification III/IV were revised more often, whereas revision in the HA cohort was performed more often in ASA I/II patients. Interpretation - After arthroplasty of hip fractures, both a posterolateral approach and an uncemented hip stem have higher risks for revision surgery compared with an anterolateral approach and an cemented stem.

The influence of bone cement and American Society of Anesthesiologists (ASA) class on cardiovascular status during bipolar hemiarthroplasty for displaced femoral-neck fracture: A multicenter, prospective, case-control study

BACKGROUND

Little is known about how bone cement and American Society of Anesthesiologists (ASA) classification influence the cardiovascular system in elderly patients with femoral-neck fractures treated with cemented hemiarthroplasty. Therefore, we performed a case-control study to investigate these questions and compared the following:≥ASA III with≤ASA II patients who underwent cemented hemiarthroplasty; and cemented with cementless hemiarthroplasty in≥ASA III patients.

HYPOTHESIS

ASA classification influences the cardiovascular system during cemented hemiarthroplasty and bone cement influences intraoperative blood pressure [IBP] in patients rated≥ASA III.

MATERIALS AND METHODS

This multicenter, prospective study included patients with acute displaced femoral-neck fractures. Baseline data, medical history, anesthesia, FiO₂, vasopressor use, femoral component, IBP, SpO₂, and complications were evaluated. Of 200 patients, 100 were cemented (mean age, 77±10 years), and 100 were cementless (mean age, 78±9 years). Cemented hemiarthroplasty employed a third-generation technique (plugging, irrigating, drying and filling the canal with cement under pressurization).

RESULTS

Systolic blood pressure (SBP) decreased significantly during cementing, versus pre-rasping in≤ASA II patients (from 117.9±24.5 [range, 65-199] to 106.9±20.3 [range, 59-172]; p=0.007), in≥ASA III patients (from 129.5±21.0 [range, 90-169] to 110.4±17.9 [range, 79-157]; p=0.006), and post-stem-insertion, versus pre-rasping in≤ASA II patients (from 117.9±24.5 [range, 65-199] to 103.9±20.7 [range, 53-178]; p=0.0004), and in≥ASA III patients (from 129.5±21.0 [range, 90-169] to 111.2±24.6 [range, 70-156]; p=0.009). In≥ASA III patients, SBP decreased significantly during cementing or rasping, versus pre-rasping in cemented patients (from 129.5±21.0 [range, 90-169] to 110.4±17.9 [range, 79-157]; p=0.006), in cementless patients (from 115.0±17.7 [range, 85-150] to 100.7±15.7 [range, 75-142]; p=0.004), and post-stem-insertion, versus pre-rasping in cemented patients (from 129.5±21.0 [range, 90-169] to 111.2±SD [range]; p=0.009), and in cementless patients (from 115.0±17.7 [range, 85-150] to 89.4±17.5 [range, 58-140]; p<0.0001). There were no lethal complications.

CONCLUSIONS

This study indicate a similar hemodynamic change intraoperatively between≤ASA II patients and≥ASA III patients in the cemented group, and between patients with cemented and cementless hemiarthroplasty in the≥ASA III patients. With modern hemiarthroplasty techniques, bone cement might be as safe as cementless techniques in elderly,≥ASA III patients.

LEVEL OF EVIDENCE

III, multicenter case-control cohort study.

Total Hip Arthroplasty for Periacetabular Metastatic Disease. An Original Technique of Reconstruction According to the Harrington Classification

BACKGROUND

Periacetabular metastatic disease requires complex acetabular reconstruction. The complication rate for these frail patients is high. Various cement-rebar reinforced techniques allowing cemented total hip arthroplasty (THA) have been described. The optimal procedure has not yet been identified.

METHODS

A continuous series of 131 THAs performed in 126 patients with periacetabular metastatic disease was prospectively included in this study. After bone metastasis curettage and cementation, an original technique of acetabular reconstruction was performed using a dual mobility cup cemented into an acetabular reinforcement device (ie, Kerboull cross-plate or Burch-Schneider antiprotrusio cage) according to the Harrington classification. Functional outcome for independent ambulation in the community, pain relief, and occurrence of dislocation or mechanical failure of the acetabular reconstruction were assessed.

RESULTS

At a mean follow-up of 33 ± 17 months, the improvement in the preoperative to postoperative functional outcome and pain relief was significant (P < .001). The dislocation rate was 2%. Two of the 3 cases of dislocation occurred in acetabular reconstructions associated with a proximal femoral arthroplasty. No mechanical failure or aseptic loosening of the acetabular reconstruction was observed.

CONCLUSION

This study emphasized that our original technique combining bone metastasis curettage and cementation, acetabular reinforcement device and cemented dual mobility cup was effective to restore a painless functional independence and ensure a durable acetabular reconstruction able to face to adjuvant radiation therapy and mechanical solicitations for long survivors. In addition, dual mobility cup limited the risk of dislocation in patients undergoing THA for periacetabular metastatic disease.

Evaluation of hemodynamic goal-directed therapy to reduce the incidence of bone cement implantation syndrome in patients undergoing cemented hip arthroplasty - a randomized parallel-arm trial

BACKGROUND

The bone cement implantation syndrome (BCIS) is a frequent and potentially disastrous intraoperative complication in patients undergoing cemented hip arthroplasty. Several risk factors have been identified, however randomized controlled trials to reduce the incidence of BCIS are still pending. We hypothesized that goal-directed hemodynamic therapy guided by esophageal Doppler monitoring (EDM) may reduce the incidence of BCIS in a randomized, controlled parallel-arm trial.

METHODS

After approval of the local ethics committee, 90 patients scheduled for cemented hip arthroplasty at the Medical Center - University of Freiburg were randomly assigned to either standard hemodynamic management or goal-directed therapy (GDT) guided by an esophageal Doppler monitoring-based algorithm. The primary endpoint was the incidence of overall BCIS including grade 1-3 after cementation of the femoral stem. Secondary endpoints included cardiac function, length of hospital stay and postoperative complications.

RESULTS

Ninety patients were finally analyzed. With regards to the primary endpoint, the overall incidence of BCIS showed no difference between the GDT and control group. Compared to the control group, patients of the GDT group showed a higher cardiac index before and after bone cement implantation (2.7 vs. 2.2 [l●min^- 1●m^- 2]; 2.8 vs. 2.4 [l●min^- 1●m^- 2]; P = 0.003, P = 0.042), whereas intraoperative amount of fluids and mean arterial pressure did not differ.

CONCLUSIONS

The implementation of a specific hemodynamic goal-directed therapy did not reduce the overall incidence of BCIS in patients undergoing cemented hip arthroplasty.

TRIAL REGISTRATION

This randomized clinical two-arm parallel study was approved by the local Ethics Committee, Freiburg, Germany [EK 160/15, PI: U. Goebel] and registered in the German Clinical Trials Register ( DRKS No. 00008778 , 16th of June, 2015).

Changes in Rehabilitation Outcomes by new Guidelines of Hong Kong Hospital Authority in Implant Choice for Femoral Neck Fractures—Austin Moore versus Cemented Exeter Hemiarthroplasty

Background

In 2013, Hospital Authority of Hong Kong replaced Austin Moore Arthroplasty (AMA) with cemented Exeter hemiarthroplasty for displaced femoral neck fractures. This study evaluated whether this new guidelines resulted in better mortality, hospital service reattendances and rehabilitation outcomes.

Methods

Patients aged 65–84 years with hemiarthroplasty done in a tertiary hospital during 2012–2014 were reviewed retrospectively. AMA group included AMAs carried out during years 2012–2013, and Exeter group included cemented modular Exeter hemiarthroplasties carried out during years 2013–2014. All patients were followed-up for 2 years.

Results

The Exeter group performed significantly better in rehabilitation outcomes than AMA group in terms of mobility score, independent and outdoor walking and community dwelling. They also had less hospital service reattendances due to falls, refractures and implant-related causes. There was a trend towards lower mortality in the Exeter group with increasing duration from operation.

Conclusion

The new guidelines in replacing AMA with cemented Exeter hemiarthroplasty resulted in better patient outcomes.

Cementless Stem for Femoral Neck Fractures in a Patient’s 10th Decade of Life: High Rate of Periprosthetic Fractures

Background:

Subsidence of cementless femoral stems in hemiarthroplasty (HA) and increased fracture rates are ongoing concerns of orthopedic surgeons when treating fractures in very old patients. Additionally, bone cement implantation syndrome may result in perioperative cardiac or pulmonary complications, especially in older patients, leading to morbidity and mortality. This study was performed to analyze possible subsidence and intraoperative fractures in a cohort of very old patients treated with cementless stems.

Methods:

We retrospectively analyzed a consecutive cohort of patients aged ≥90 years with femoral neck fractures treated by uncemented HA and an anterior minimally invasive approach. Immediate full-weight bearing was allowed postoperatively. Pelvic radiographs were examined for subsidence immediately postoperatively and 6 weeks later.

Results:

We treated 109 patients (74% women; mean age, 93 years; range, 90-102 years) by HA from January 2010 to March 2016. The 30-day mortality rate was 16%, and the morbidity rate was 47%. There were 11 (12%) intraoperative fractures: 8 (Vancouver B₂) had to be addressed immediately during the primary operation, while 3 (1 Vancouver B₁ and 2 Vancouver A_G) were treated conservatively. One periprosthetic femoral fracture (Vancouver B₁) was documented during follow-up. In 17 patients, subsidence of >2.0 mm (median, 3.9 mm; range, 2.5-9.0 mm) was documented.

Conclusion:

Early subsidence was low in this very old cohort treated with an uncemented stem and not showing a periprosthetic fracture. The risk of intraoperative periprosthetic fractures was high. The use of uncemented implants in osteoporotic bone continues to be an intervention with high risk and should only be performed by experienced surgeons.

Level of Evidence:

Level III, Therapeutic study.

Cardiovascular ultrasonography detection of embolic sources in trauma

Venous thromboembolism (deep vein thrombosis and pulmonary embolism) and bone cement implantation syndrome are major sources of embolic events in trauma patients. In these patients, embolic events due to venous thromboembolism and bone cement implantation syndrome have been detected with cardiac and vascular ultrasonography in the emergency setting, during the perioperative period, and in the intensive care unit. This article discusses the ultrasonography modalities and imaging findings of embolic events related to venous thromboembolism and bone cement implantation syndrome. The aim is to present a short review with exceptional illustrations that can enable physicians to identify sources of emboli in trauma patients with cardiovascular ultrasonography.