Adequate surgical treatment of periprosthetic femoral fractures following hip arthroplasty does not correlate with functional outcome and quality of life

Risk factors for mortality in periprosthetic femur fractures about the hip-a retrospective analysis

PURPOSE

Fractures around the hip are known to be an indicator for fragility and are associated with high mortality and various complications. A special type of fractures around the hip are periprosthetic femur fractures (PPF) after Total Hip Arthroplasty (THA). The aim of this study was to investigate the mortality rate associated with PPF after THA and to identify risk factors that may increase it.

METHODS

Consecutive patients (N = 158) who were treated for a PPF after THA in our university hospital between 2010 and 2020 were identified and mortality was assessed using the residential registry. Univariate (Kaplan-Meier-Estimator) and multivariate (Cox-Regression) statistical analysis was performed to identify risk factors influencing mortality.

RESULTS

One-year-mortality rate was 23.4% and 2-year mortality was 29.2%. Mortality was significantly influenced by age, gender, treatment, type of comorbidity and time of surgery (p < 0.05). Surgical treatment during regular working hours (8 to 18 h) reduced mortality by 53.2% compared to surgery on call (OR: 0.468, 95% CI 0.223, 0.986; p = 0.046). For every year of age, mortality risk increased by 12.9% (OR: 1,129, 95% CI 1.078, 1.182; p < 0.001). The type of fracture according to the Vancouver classification had no influence on mortality (p = 0.179). Plate fixation and conservative treatment were associated with a higher mortality compared to revision arthroplasty (plate: OR 2.8, 95% CI 1.318, 5.998; p = 0.007; conservative: OR 2.5, 95% CI 1.421, 4.507; p = 0.002).

CONCLUSION

Surgical treatment during regular working hours is associated with lower mortality compared to surgery outside these hours. In this retrospective cohort, time to surgery showed no significant impact on all-cause mortality, and revision arthroplasty was associated with lower mortality than conservative treatment or plate fixation.

LEVEL OF EVIDENCE

IV (Retrospective cohort study).

The Effect of Periprosthetic Fractures Following Total Hip and Knee Arthroplasty on Long-Term Functional Outcomes and Quality of Life

Background

Periprosthetic fractures (PPFs) after total joint arthroplasty (TJA) can be devastating, yet their long-term impact has not been well described. The aim of this study is to compare the long-term outcomes of patients who sustained a PPF about a TJA with those of patients who underwent an uncomplicated TJA.

Methods

Patients who sustained a PPF after primary TJA between 2005 and 2014 were identified. Seventeen patients with a minimum 2-year follow-up (PPF cohort) were compared to a matched cohort of 67 patients who underwent uncomplicated TJA. Demographic data, comorbidities, surgical details, and complications were analyzed. Quality of life and functional outcomes were assessed with 12-Item Short Form Health Survey (SF-12), Western Ontario and McMasdter Universities Arthritis Index (WOMAC), and Knee Society Function Score.

Results

The overall complication rate was 41.2% in the PPF group, including 3 additional fractures (17.6%), 2 wound infections (11.8%), one prosthetic joint infection (5.8%), and one painful patellar hardware necessitating removal (5.8%). At 2 years, both physical and mental components of the SF-12 were significantly lower for the PPF cohort vs control (SF-12-P, 28.7 ± 4.4 vs 40.8 ± 10.3, P < .001, SF-12-M, 36.7 ± 5.07 vs 55.0 ± 8.19, P < .0001). WOMAC pain and function scores were also significantly worse in the PPF cohort vs control at 2 years (WOMAC-pain, 38.8 ± 29.9 vs 87.4 ± 22.1; P < .0001, WOMAC-function, 40.7 ± 8.7 vs 76.1 ± 20.3; P < .0001). At 2 years, score improvements from prearthroplasty baseline were significantly greater in the control cohort vs PPF for SF-12-physical, WOMAC-pain, and WOMAC-function.

Conclusions

Patients who sustained PPFs following TJA have poor long-term outcomes despite appropriate treatment. These results can help counsel patients and encourage heightened efforts to minimize the risk of PPF.

Level of Evidence

Level III.

[Concept for the treatment of periprosthetic proximal femoral fractures]

Due to demographic changes and increased survival rates of total hip arthroplasties, the incidence of periprosthetic proximal femoral fractures is increasing. The current treatment concept requires accurate preoperative planning. Besides patient-related risk factors, fracture type, prosthesis stability, and bone quality influence whether osteosynthesis or a revision arthroplasty is required.

Health status after periprosthetic proximal femoral fractures

Aims

Periprosthetic proximal femoral fractures (PFFs) are a major complication after total hip arthroplasty (THA). Health status after PFF is not specifically investigated. The aim of this study is to evaluate the health status pattern over two years after sustaining a PFF.

Methods

A cohort of patients with PFF after THA was derived from the Brabant Injury Outcomes Surveillance (BIOS) study. The BIOS study, a prospective, observational, multicentre follow-up cohort study, was conducted to obtain data by questionnaires pre-injury and at one week, and one, three, six, 12, and 24 months after trauma. Primary outcome measures were the EuroQol five-dimension three-level questionnaire (EQ-5D-3L), the Health Utility Index 2 (HUI2), and the Health Utility Index 3 (HUI3). Secondary outcome measures were general measurements such as duration of hospital stay and mortality.

Results

A total of 70 patients with a PFF were included. EQ-5D utility scores were significantly lower on all timepoints except at six months' follow-up compared to pre-injury. EuroQol visual analogue scale (EQ-VAS) scores at one month's follow-up were significantly lower compared to pre-injury. The percentage of reported problems at two years was higher for all dimensions except anxiety/depression when compared to pre-injury. The mean EQ-5D utility score was 0.26 higher in males compared to females (95% confidence interval (CI) 0.01 to 0.42; p = 0.003). The mean EQ-VAS score for males was 8.9 points higher when compared to females over all timepoints (95% CI 1.2 to 16.7; p = 0.027). Mortality was 10% after two years' follow-up.

Conclusion

PFF patients are a frail population with substantial functional impairment at baseline. Post-injury, they have a significant and clinically relevant lower health status two years after trauma when compared to pre-injury. Health status improves the most between one and three months after injury. Two years after PFF, more patients experience problems in mobility, self-care, usual activities, and pain/discomfort than pre-injury.

What Are the Mortality, Infection, and Nonunion Rates After Periprosthetic Femoral Fractures in the United States?

BACKGROUND

Periprosthetic femoral fractures are a serious complication that put a high burden on patients. However, comprehensive analyses of their incidence, mortality, and complication rates based on large-registry data are scarce.

QUESTIONS/PURPOSES

In this large-database study, we asked: (1) What is the incidence of periprosthetic femoral fractures in patients 65 years and older in the United States? (2) What are the rates of mortality, infection, and nonunion, and what factors are associated with these outcomes?

METHODS

In this retrospective, comparative, large-database study, periprosthetic femoral fractures occurring between January 1, 2010, and December 31, 2019, were identified from Medicare physician service records encompassing services rendered in medical offices, clinics, hospitals, emergency departments, skilled nursing facilities, and other healthcare institutions from approximately 2.5 million enrollees. These were grouped into proximal, distal, and shaft fractures after TKA and THA. We calculated the incidence of periprosthetic femur fractures by year. Incidence rate ratios (IRR) were calculated by dividing the incidence in 2019 by the incidence in 2010. The Kaplan-Meier method with Fine and Gray subdistribution adaptation was used to calculate the cumulative incidence rates of mortality, infection, and nonunion. Semiparametric Cox regression was applied with 23 measures as covariates to determine factors associated with these outcomes.

RESULTS

From 2010 to 2019, the incidence of periprosthetic femoral fractures increased steeply (TKA for distal fractures: IRR 3.3 [95% CI 1 to 9]; p = 0.02; THA for proximal fractures: IRR 2.3 [95% CI 1 to 4]; p = 0.01). One-year mortality rates were 23% (95% CI 18% to 28%) for distal fractures treated with THA, 21% (95% CI 19% to 24%) for proximal fractures treated with THA, 22% (95% CI 19% to 26%) for shaft fractures treated with THA, 21% (95% CI 18% to 25%) for distal fractures treated with TKA , 22% (95% CI 17% to 28%) for proximal fractures treated with TKA, and 24% (95% CI 19% to 29%) for shaft fractures treated with TKA. The 5-year mortality rate was 63% (95% CI 54% to 70%) for distal fractures treated with THA, 57% (95% CI 54% to 62%) for proximal fractures treated with THA, 58% (95% CI 52% to 63%) for shaft fractures treated with THA, 57% (95% CI 52% to 62%) for distal fractures treated with TKA , 57% (95% CI 49% to 65%) for proximal fractures treated with TKA, and 57% (95% CI 49% to 64%) for shaft fractures treated with TKA. Age older than 75 years, male sex, chronic obstructive pulmonary disease (HR 1.48 [95% CI 1.32 to 1.67] after THA and HR 1.45 [95% CI 1.20 to 1.74] after TKA), cerebrovascular disease after THA, chronic kidney disease (HR 1.28 [95% CI 1.12 to 1.46] after THA and HR 1.50 [95% CI 1.24 to 1.82] after TKA), diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis were clinical risk factors for an increased risk of mortality. Within the first 2 years, fracture-related infections occurred in 5% (95% CI 4% to 7%) of patients who had distal fractures treated with THA, 5% [95% CI 5% to 6%]) of patients who had proximal fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had shaft fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had distal fractures treated with TKA , 7% (95% CI 5% to 9%) of patients who had proximal fractures treated with TKA, and 6% (95% CI 4% to 8%) of patients who had shaft fractures treated with TKA. Nonunion or malunion occurred in 3% (95% CI 2% to 4%) of patients with distal fractures treated with THA, 1% (95% CI 1% to 2%) of patients who had proximal fractures treated with THA, 2% (95% CI 1% to 3%) of patients who had shaft fractures treated with THA, 4% (95% CI 3% to 5%) of those who had distal fractures treated with TKA, , 2% (95% CI 1% to 4%) of those who had proximal fractures treated with TKA, and 3% (95% CI 2% to 4%) of those who had shaft fractures treated with TKA.

CONCLUSION

An increasing number of periprosthetic fractures were observed during the investigated period. At 1 and 5 years after periprosthetic femur fracture, there was a substantial death rate in patients with Medicare. Conditions including cerebrovascular illness, chronic kidney disease, diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis are among the risk factors for increased mortality. After the surgical care of periprosthetic femur fractures, the rates of fracture-related infection and nonunion were high, resulting in a serious risk to affected patients. Patient well-being can be enhanced by an interdisciplinary team in geriatric traumatology and should be improved to lower the risk of postoperative death. Additionally, it is important to ensure that surgical measures to prevent fracture-related infections are followed diligently. Furthermore, there is a need to continue improving implants and surgical techniques to avoid often-fatal complications such as fracture-associated infections and nonunion, which should be addressed in further studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Evaluating the Functional and Psychological Outcomes Following Periprosthetic Femoral Fracture After Total Hip Arthroplasty

Background

A fall after total hip arthroplasty (THA) that results in a periprosthetic femoral fracture (PPF) can have devastating functional and psychological consequences in older adults. There are few studies that have evaluated both functional and psychological outcomes of PPF post-THA in the same cohort.

Methods

This is a retrospective study of 130 people who underwent revision THA between 2005 and 2019 due to PPF. The Western Ontario and McMaster Universities Osteoarthritis (WOMAC), Harris Hip Score (HHS), and Short Form-12 (SF-12) assessed physical function, hip joint function, and psychological well-being, respectively. Descriptive statistics using means and standard deviation or frequencies and percentages were used to define the sample. The association between baseline demographic, clinical, and surgical factors on WOMAC, HHS, and SF-12 scores at 1-year post-PPF surgery was modelled using multivariable linear regression. The mean age (n = 130) was 80.6 ± 9.0 years, and 55.4% (n = 72) were female. The mortality rate was 15.4% (n = 20) at 1-year post-PPF surgery. One-year follow-up data were available for 35.4% (n = 46) of patients.

Results

The WOMAC (n = 37), HHS (n = 32), and SF-12 mental component summary (n = 46) scores at 1-year post-PPF surgery were 67.9 ± 20.3, 78.3 ± 15.0, and 52.7 ± 9.1, respectively. No significant association was found among age, gender, previous history of lower extremity surgery, Vancouver classification, and femoral bone grafting on WOMAC, HHS, and SF-12 scores.

Conclusions

Our study found that patients with PPF have fair hip joint function, poor physical function and psychological well-being, and a high mortality rate at 1-year post-PPF surgery.

Periprosthetic femoral fractures in Total Hip Arthroplasty (THA): a comparison between osteosynthesis and revision in a retrospective cohort study

Background

Periprosthetic femoral fractures are challenging complications of hip arthroplasty. They are supposed to be a rare complication, but their incidence is rapidly increasing. Surgical treatment aims to achieve early mobilization and avoid the complications of prolonged bed rest. Aim of this study is to evaluate the clinical outcomes of surgical treatment comparing two surgical approaches: revision arthroplasty (RA) versus open reduction and internal fixation (ORIF).

Methods

Authors retrospectively reviewed a series of 117 patients with total hip arthroplasty treated for periprosthetic femur fractures in the period between January 2013 and March 2018 at a single tertiary referral center. Of these, 70 patients satisfied strict inclusion criteria. Patients were classified according to the Unified Classification System (UCS) and distributed in two groups according to surgical treatment. Clinical outcomes were assessed using the Oxford Hip recorded preoperatively and post operatively, Barthel Score, CIRS score (Cumulative illness rating scale), type of fracture and post-operative complications with a minimum follow up of 1 year.

Results

Nominal univariate statistical analysis revealed significant differences between the post and pre-operative Oxford Hip Score (Δ Oxford) and the surgical treatment (p = 0.008) and CIRS score (p = 0.048). Moreover, we observed a significant relationship between type of treatment and type of fracture (p = 0.0001). Multivariate analyses revealed that CIRS score was independently associated with Oxford Score improvement after surgery (p = 0.024).

Conclusions

Data from this case series confirmed that surgical treatment was correlated to type of fracture, according to UCS classification. Patients treated by RA had a better functional outcome than patients treated with ORIF, but these results are strongly influenced from the patients’ age, Barthel index and CIRS score. Also, authors found a correlation between functional outcome and comorbidities evaluated by CIRS score. Based on these data we suggest a multimodal approach to these patients, like those used for proximal femoral fractures.

LOQTEQ® VA Periprosthetic Plate-A New Concept for Bicortical Screw Fixation in Periprosthetic Fractures: A Technical Note

Internal fixation using angle stable plates is the treatment standard in periprosthetic fractures around stable implants. To provide instant postoperative full weight-bearing, bicortical screw fixation is advisable but often surgically demanding. This work presents the first clinical results of the LOQTEQ^® VA Periprosthetic Plate (aap Implantate AG, Berlin, Germany), a new plate system to simplify screw placement around implants. This plate system uses insertable hinges that allow for variable angle screw anchorage. Data of 26 patients with a mean age of 80 years and a mean follow-up of 13.9 months were retrospectively collected. Patients were clinically and radiologically examined. Bony union was achieved in 14 out of 15 patients with no signs of non-union or implant loosening. One patient, however, presented with implant failure. Clinical scores demonstrated acceptable results. Since the hinge plates are easy to apply, the first results are promising.

Mortality After Postoperative Periprosthetic Fracture of the Femur After Hip Arthroplasty in the Last Decade: Meta-Analysis of 35 Cohort Studies Including 4841 Patients

BACKGROUND

Postoperative periprosthetic fracture of the femur (POPFF) is associated with increased mortality. There is a lack of general estimates of mortality after POPFF and a need for higher-level evidence in this area. The aim of this study was to estimate mortality after POPFF using data reported in cohort studies from the last decade.

METHODS

Literature search was conducted using Medline and Embase. The primary outcome was all-cause mortality during time as an inpatient, within 30 days, within 90 days, and within one year of POPFF. Mortality (95% confidence interval [CI]) was estimated using metaregression.

RESULTS

A total of 4841 patients from 35 cohort studies were included. Study quality was generally low. The weighted mean follow-up was 2.3 years, and the most common POPFF was Vancouver B. The pooled mortality as an inpatient was 2.4% (95% CI 1.6% to 3.4%). The pooled mortality within 30 days was 3.3% (95% CI 2.0% to 5.0%). The pooled mortality within 90 days was 4.8% (95% CI 3.6% to 6.1%). The pooled mortality within one year was 13.4% (95% CI 11.9% to 14.8%). Mortality after POPFF was like that of neck of femur fracture up to 30 days, but better at one year.

CONCLUSION

Mortality is like that experienced by patients after neck of femur fracture up to 30 days, but better at one year, which may represent the lower underlying risk of death in the POPFF cohort. These results may form the basis for evaluation of services treating POPFF in the future.

A case-control study of 30-day mortality in periprosthetic hip fractures and hip fractures

INTRODUCTION

There are increasing numbers of periprosthetic femoral fractures, which have high mortality rates. These fractures occur in a similar demographic to hip fractures. There has been limited research on mortality following these fractures. This study compared 30-day mortality in periprosthetic hip fractures with case-matched hip fractures.

MATERIALS AND METHODS

Case notes of periprosthetic hip fractures between 1 January 2009 and 31 December 2015 were reviewed retrospectively at a single institution. There were 173 periprosthetic hip fractures over the seven years of the study. All hip fractures attending the same institution have data collected prospectively for the National Hip Fracture Database. Data were analysed from the Hip Fracture Database. A power calculation was undertaken; 173 periprosthetic hip fractures were matched to 865 hip fractures individually for age, sex, American Society of Anesthesiologists grade and capacity.

RESULTS

The median wait to surgery was 88 hours for periprosthetic fractures and 23 hours for hip fractures (p < 0.00001); 22.5% of patients with periprosthetic fractures underwent surgery within 36 hours compared with 68.2% of those with hip fractures (p < 0.0001). The median length of stay was 16 days for periprosthetic fractures and 10 days for hip fractures (p < 0.00001). The 30-day mortality was 6.4% for periprosthetic hip fractures and 3.1% for case-matched hip fractures (odds ratio 2.11, 95% confidence interval 1.03-4.36; p = 0.043).

CONCLUSIONS

Periprosthetic hip fractures have a significantly higher mortality than hip fractures. Further research should aim to improve outcomes in these patients.

Perceived occurrence of an adverse event affects patient-reported outcomes after total hip replacement

Background

Dislocation, periprosthetic fracture and infection are serious complications of total hip replacement (THR) and which negatively impact on patients’ outcomes including satisfaction, quality of life, mental health and function. The accuracy with which patients report adverse events (AEs) after surgery varies. The impact of patient self-reporting of AEs on patient-reported outcome measures (PROMs) after THR is yet to be investigated. Our aim was to determine the effect of confirmed and perceived AEs on PROMs after primary THR.

Methods

A prospective single-centre cohort study of patients undergoing primary THR, with one-year follow-up, was performed. Participants completed forms pre-operatively and 3, 6, 9 and 12 months post-operatively, including Work Productivity and Activity Impairment (WPAI), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EuroQol-5D-3 L (EQ5D), Self-Administered Patient Satisfaction (SAPS) and AE reporting questionnaires. Results were reported in three groups: No AE, reported but not confirmed AE and confirmed AE. A generalised linear model was used to compare among groups using robust standard errors (SE).

Results

Forty-one AEs were reported in a cohort of 417 patients (234 females), with 30 AEs reported by 3 months. Eleven (27 reported) infections, two (six reported) periprosthetic fractures and two (eight reported) dislocations were confirmed. Those in the no AE group reported significantly better outcomes that the reported AE group as measured by WOMAC Co-Eff 14.27 (p = 0.01), EQ5D − 0.128 (p = 0.02) and SAPS − 9.926 (p = 0.036) and the combined reported and confirmed AE groups as measured by WOMAC Co-Eff 13.72 (p = 0.002), EQ5D − 0.129 (p = 0.036) and SAPS − 11.512 (p = 0.004). No significant differences were seen in WPAI among groups.

Conclusions

Patients who report AEs have worse outcomes than those who do not, regardless of whether the AEs can be confirmed by standard medical record review methods. The observed negative trends suggest that patient perception of AEs may influence patient outcome in a similar way to those with confirmed AEs.

Predictors of poor functional outcomes and mortality in patients with hip fracture: a systematic review

Background

Hip fracture is an important and prevalent medical condition associated with adverse outcomes. The aim of this article is to systematically review and summarise the predictors of poor functional outcomes and mortality for patients with hip fractures.

Methods

We conducted a systemic literature search using PubMed, EMBASE and Cochrane Library. We included English peer-reviewed cohort studies that examined predictors of poor functional outcomes (such as independence in Activities of Daily Living) and mortality for patients with hip fracture published in the past 15 years (from 1 Jan 2004 up to 30 May 2019). Two independent researchers evaluated the articles for eligibility. Consensus on the eligibility was sought and a third researcher was involved if there was disagreement. A standardised form was used to extract relevant data. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies.

Results

We retrieved 4339 and included 81 articles. We identified two emerging predictors of poor functional outcomes and mortality for patients with hip fractures: low hand grip strength and frailty in line with an emerging concept of “physical performance”. The predictors identified in this systematic review can be grouped into 1) medical factors, such as presence of co-morbidities, high American Society of Anesthesiologists (ASA) grade, sarcopenia, 2) surgical factors including delay in operation (e.g. > 48 h), type of fracture s, 3) socio-economic factors which include age, gender, ethnicity, and 4) system factors including lower case-volume centers.

Conclusions

This systematic review identified multiple significant predictors of poor functional outcomes and mortality, with the hand grip strength and frailty being important emerging predictors in the most recent literature. These predictors would further inform healthcare providers of their patients’ health status and allow for early intervention for modifiable predictors.

Cemented Femoral Component Use in Hip Arthroplasty

Elderly patients undergoing both elective and nonelective hip arthroplasty contribute markedly to health care spending, and the current aging population is likely to require even more resources. Several national joint replacement registries show a lower risk of revision surgery in patients older than 75 years who received cemented femoral components compared with cementless implants for primary total hip arthroplasty. Despite a higher incidence of early periprosthetic femoral fracture, noncemented femoral components are being used with increasing frequency in elderly patients worldwide. Improvements in cementing technique and modifications to cemented stem design over several decades allow surgeons to obtain femoral component fixation in poor-quality bone with a relatively low risk of complications. Achieving durable cemented stem fixation requires the surgeon to understand the basic handling properties of cement, how to prepare the femoral bone, and differences in stem design and surface finish.

The value of a standardized and reproducible surgical technique in treatment of Vancouver B2 periprosthetic fractures: our experience

PURPOSE

To retrospectively review results and complications of our standardized surgical technique addressed exclusively to Vancouver B2 fractures.

METHODS

From January 2006 to July 2016, we treated 235 consecutive patients, 47 males and 188 females, mean age at surgery of 71 ± 10 years, with periprosthetic B2 fractures. Exclusion criteria were other kind of periprosthetic fractures and other femoral fractures. The patients were assessed clinically and radiographically following our standard protocol at the last available follow-up. The mean follow-up time was 6.4 years. Radiographic evaluation was performed according to Beals and Tower's criteria and clinical evaluation was performed using the Harris Hip Score and clinical exam.

RESULTS

From the starter cohort of 235, 207 patients (88.1%) were fully evaluated, while 28 were lost to follow-up. According to Beal and Tower's criteria, we found excellent results in 72 patients (34.8%), good results in 133 patients (64.3%), and poor results in 2 patients (0.9%). Mean HHS was 75 ± 9 points, with a statistically significant correlation between good functional results and better radiographic assessment (p = 0.001). The use of support plate (p = 0.008) and the acetabular revision (p = 0.002) showed a statistically significant distribution with worse radiographic results. Late complications detected were ten dislocations.

CONCLUSION

Our experience suggests that using a standardized and reproducible surgical technique, as our technique proposed, can surely reduce surgical time, the complication rate, and the mortality rate. During acetabular evaluation, the choice of performing a cup revision must be weighed on overall patient's assessment.

Still no single gold standard for using cementless femoral stems routinely in total hip arthroplasty

Background

There is now a clear trend with increased usage of cementless femoral stems for all ages and most patients. As the number of total hip arthroplasties (THAs) performed annually continues to increase with expanding indications for THA and demands for improved quality of life, so will the prevalence of THA in the elderly and aging populations. This is worrisome as the risk of complications with cementless femoral stems increases in elderly patients and those with poor bone quality. The purpose of this study is to analyze the available data from comparative studies to determine whether cementless femoral stems are overused and whether cemented stems warrant increased consideration.

Methods

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searches were performed to find original studies comparing cementless and cemented femoral stems; large population registry studies and reports were also included.

Results

This systematic review documents that older patients with cementless fixation increase the risk of revision, there is no clear fixation advantage in midaged patients, and younger patients fare better with cementless fixation. Complications after THA create burdens on the health care system and on patients.

Conclusions

Using evidence-based data should be better guidance in selecting the most reliable implants for THA. Although cementless femoral fixation for THA has evolved to the “new standard,” it has not been proven to be the “gold standard” for all patients.

Periprosthetic fractures: concepts of biomechanical in vitro investigations

PURPOSE

Experimental in vitro studies investigating periprosthetic fractures after joint replacement are used increasingly. The purpose of this review was to deliver a condensed survey of studies in order to provide researchers with an overview of relevant scientific results and their clinical relevance.

METHODS

A literature search was conducted to obtain all available papers dealing with periprosthetic fractures, with particular attention being paid to articles with an experimental research design. Study goals, scientific methods and results, their interpretation and clinical relevance were assessed and compared. The main focus was on comparability with clinical fracture patterns and physiological joint loads.

RESULTS

Excluding duplicates, 24 studies with regard to artificial hip, knee and shoulder joints were found dating back to August 2000. Almost all studies were performed quasi-statically and without consideration of muscle forces and thus reflect selected loading conditions and no dynamic situation during activities of daily living (ADL). Various experimental protocols were used, differing in the choice of experimental material, implant and fixation system and load application.

CONCLUSIONS

In vitro studies regarding periprosthetic fracture research allow controlling for disturbances, such as clinically occurring risk factors like reduced bone mineral density (BMD) or greater patient age. Notwithstanding, due to methodological differences, comparisons between studies were possible to a limited degree only. For this reason, and because of quasi-static loading typically applied, results can only be partially applied to clinical practice.