The worst-case scenario: treatment of periprosthetic femoral fracture with coexistent periprosthetic infection-a prospective and consecutive clinical study

Analysis of complications in 97 periprosthetic Vancouver B2 fractures treated either by internal fixation or revision arthroplasty

INTRODUCTION

The treatment of Vancouver B2 periprosthetic fractures after hip arthroplasty is still a matter of debate. Revision Arthroplasty (RA) was long thought to be the treatment of choice, however several recent papers suggested that Open Reduction and Internal Fixation (ORIF) is a viable option for selected B2 fractures. Complication rates of 14-26% have been reported following surgical treatment of B2 fractures. No significant difference between RA and ORIF in the complication rates nor in the functional outcome was observed.

METHOD

We conducted a retrospective analysis of 97 consecutive Vancouver B2 fractures treated according to the algorithm at our institution from 2007 to 2020 and recorded complications and patient specific data.

RESULT

From the 97 patient, 45 fractures were treated with RA while 52 fractures were treated with ORIF. Thirteen patients in the RA group had a complication that needed revision (28%) and 11 patients in the ORIF group needed revision (21%). There was no significant difference between complication rates. The reason for failure in the 13 RA patients were infection (n = 4), stem subsidence (n = 1), refracture after a new fall (n = 3), secondary dislocation of the greater trochanter (n = 1) and dislocation (n = 4). The reason for failure in the 11 ORIF patients that were revised were infection (n = 5), persistent symptomatic stem loosening (n = 3) and refracture (n = 3) after a new fall.

CONCLUSION

ORIF can be used to revise cemented and non-cemented shafts in more than half of Vancouver B2 fractures with no difference in complication rates when compared to RA. A periprosthetic fracture around the hip has a 21-28% risk of a re-operation after revision surgery with infection and re-fracture after a new fall being the most frequent cause of re-operation.

Early-Outcome Differences between Acute and Chronic Periprosthetic Joint Infections-A Retrospective Single-Center Study

Periprosthetic joint infections (PJI) are serious complications after arthroplasty, associated with high morbidity, mortality, and complex treatment processes. The outcomes of different PJI entities are largely unknown. The aim of this study was to access the early outcomes of different PJI entities. A retrospective, single-center study was conducted. The characteristics and outcomes of patients with PJI treated between 2018 and 2019 were evaluated 12 months after the completion of treatment. Primary endpoints were mortality, relapse free survival (RFS) and postoperative complications (kidney failure, sepsis, admission to ICU). A total of 115 cases were included [19.1% early (EI), 33.0% acute late (ALI), and 47.8% chronic infections (CI)]. Patients with ALI were older (p = 0.023), had higher ASA scores (p = 0.031), preoperative CRP concentrations (p = 0.011), incidence of kidney failure (p = 0.002) and sepsis (p = 0.026). They also tended towards higher in-house mortality (ALI 21.1%, 13.6% EI, 5.5% CI) and admission to ICU (ALI 50.0%, 22.7% EI, 30.9% CI). At 12 months, 15.4% of patients with EI had a relapse, compared to 38.1% in ALI and 36.4% in CI. There are differences in patient characteristics and early outcomes between PJI entities. Patients with EI have better early clinical outcomes. Patients with ALI require special attention during follow-up because they have higher occurrences of relapses and postoperative complications than patients with EI and CI.

Treatment of periprosthetic knee infection and coexistent periprosthetic fracture: A case report and literature review

BACKGROUND

Periprosthetic joint infection (PJI) and periprosthetic fracture (PPF) are among the most serious complications following total knee arthroplasty. Herein, we present one patient with these two complications with details on the characteristics, treatment strategy, and outcome.

CASE SUMMARY

A 69-year-old female patient who suffered from PJI and PPF following total knee arthroplasty was treated by a two-stage revision surgery. After thorough foreign material removal and debridement, we used a plate that was covered with antibiotic-loaded bone cement to link with a hand-made cement spacer to occupy the joint space and fix the fracture. Although the infection was cured, the fracture did not heal and caused bone defect due to the long interval between debridement and revision. In the revision surgery, a cemented stem and cortical allogenic splints were used to reconstruct the fracture and bone defect. At the final follow-up 27 mo after revision, the patient was satisfied with postoperative knee functions with satisfactory range of motion (104º) and Hospital for Special Surgery knee score (82 points). The radiographs showed no loosening of the prosthesis and that the bone grafts healed well with the femur.

CONCLUSION

Our two-stage revision surgery has proved to be successful and may be considered in other patients with PJI and PPF.

Two-stage exchange for PJI with co-existing cerclages for fracture: higher rates of early re-infections and difficult to treat microbes

INTRODUCTION

Periprosthetic joint infections (PJI) with osteosynthesis material for contemporaneous fractures are a challenging, yet poorly described condition. This study will analyze PJI with co-existing fractures treated with cerclages and two-stage exchange.

MATERIALS AND METHODS

Patients with and without cerclages for coexisting periprosthetic fractures, undergoing two-stage exchange for PJI of hip or knee, between 06/2013 and 02/2016, were compared concerning baseline characteristics and re-infection rate in the course of a 2 year follow-up. All patients were treated with a standardized two-stage protocol. A PJI was defined according to the EBJIS criteria. All foreign material, including cerclages, was sent in for sonication for microbiological analysis.

RESULTS

Ninety-six patients treated with two-stage exchange for PJI could be included. Co-existing fractures treated with cerclage were identified in nine patients (9.3%, study group). Diaphyseal femoral simple in five cases (AO2A3) and proximal intertrochanteric in three cases (AO1A3) were the leading fracture locations. In one patient, cerclage implantation was performed prior to prosthesis explantation, in six, during prosthesis explantation, and in two, in the course of prosthesis reimplantation. The study group showed a significantly higher rate of difficult to treat microbes (44.4%; 8.0%; p = .001), Charlson Comorbidity Index (5.4; 3.7; p = .033), relapse infections with the same microbe (22.2%; 1.1%; p = .001), and early-onset infections (< 30 days) (11.1%; 1.1%; p = .046), than the comparison two-stage exchange group without fractures. In contrast, age (72.5 study group; 68.2 comparison group; p = .224), rate of revisions for PJI in the past (55.5%; 51.7%; p = .827), and total re-infection rate (22.2%; 10.3%; p = .287) did not show a difference.

CONCLUSION

PJI with co-existing cerclages for fractures were associated with multi-resistant microbes, relapse by the same microbe and early-onset re-infections. Cerclages might be considered a potential source of re-infection during a two-stage exchange. However, statistical weaknesses and a small study group must be considered limitations of the study.

[Individual megaspacers in two-stage revision of infected total hip arthroplasty-clinical and functional results after 2 years : Individual metal-endoskeleton cement spacer (iMECS)]

BACKGROUND

Large femoral defects in late periprosthetic infection (PPI) after total hip arthroplasty (THA) often require the use of large, individual metal endoskeleton-reinforced cement spacers (iMECS).

OBJECTIVES

The aim was to record the clinical, radiological and functional results (Harris Hip Score HHS) up to the 2 years after treatment of a PPI using an iMECS. Major patient-specific parameters were to be evaluated with regard to the treatment outcome.

MATERIALS AND METHODS

The collective of this single-center retrospective cohort study comprised 29 patients. The mean follow-up was 24.4 months (range: 23.0 to 27.6 months). The absence of infection after endoprosthetic hip joint reconstruction was rated as successful treatment. The two patient groups (successful (S)/not successful (nS)) were compared with regard to gender distribution, the Charlson comorbidity index (CCI), the number of previous septic changes, and the rate of polymicrobial and difficult-to-treat infections.

RESULTS

The average CCI in the total collective was 6.4 points. Joint reconstruction was possible in 23 of 29 patients (79%); 2 years after PPI treatment 4 patients were not available for a follow-up examination (2 deceased, 2 unable to participate). At the time of the follow-up, 17 of the 29 patients had received a joint reconstruction and were free of infection, with an average HHS of 75 points. There were no iMECS-associated complications requiring revision. Only the initial CCI (S: 4.1 points; nS: 9.7 points) differed significantly between the patient groups (p < 0.05).

CONCLUSIONS

In the case of large femoral defects, iMECS provide secure temporary stabilization. The chance of a successful joint reconstruction is closely related to the individual comorbidities profile.

The race for the classification of proximal periprosthetic femoral fractures : Vancouver vs Unified Classification System (UCS) - a systematic review

Background

Periprosthetic femoral fractures (PFFs) represent a major cause for surgical revision after hip arthroplasty with detrimental consequences for patients. The Vancouver classification has been traditionally used since its introduction in 1995. The Unified Classification System (UCS) was described in 2014, to widen the spectrum by aiming for a more comprehensive approach. The UCS also aimed to replace the Vancouver classification by expanding the idea of the Vancouver classification to the whole musculoskeletal apparatus. After introduction of the UCS, the question was raised, whether the UCS found its place in the field of analysing PFFs. Therefore, this systematic review was performed to investigate, the use of the UCS compared to the established Vancouver classification.

Methods

Medline was searched for reports published between 1 January 2016 and 31 November 2020, without language restriction. Included were original articles, irrespective of the level of evidence and case reports reporting on a PFF and using either the Vancouver or the UCS to classify the fractures. Excluded were reviews and systematic reviews.

Results

One hundred forty-six studies were included in the analysis. UCS has not been used in a single registry study, giving a pooled cohort size of 3299 patients, compared to 59,178 patients in studies using the Vancouver classification. Since 2016, one study using UCS was published in a top journal, compared to 37 studies using the Vancouver classification (p=0.29). During the study period, the number of yearly publications remained stagnant (p=0.899).

Conclusions

Despite valuable improvement and expansion of the latter UCS, to date, the Vancouver system clearly leads the field of classifying PFFs in the sense of the common use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05240-w.

Experience with periprosthetic infection after limb salvage surgery for patients with osteosarcoma

Background

The rate of postoperative infection developing is higher after limb salvage surgery (LSS) following sarcoma resection compared with conventional arthroplasty. The goal of this study is to summarize our experience in management of periprosthetic joint infection (PJI) and the risk factors of early PJI after LSS.

Methods

Between January 2010 and July 2019, 53 patients with osteosarcoma in the lower extremities who encountered periprosthetic infection after segmental tumor endoprosthetic replacement in our center were analyzed. Detailed patient characteristics and therapeutic information were collected from database of our institution or follow-up data and we divided patients according to the interval time between infection and tumor resection (surgery-infection interval) and investigate potential risk factors.

Results

A total of 53 (5.08%) patients were suffered postoperative infection. The average interval between surgery and clinical signs of deep infections are 27.5 days. For the drainage culture, positive results were only presented in 11 patients (20.8%). Almost half of this study’s (47.2%) patients underwent a traditional two-stage revision, that was, after the removal of the infected prosthesis, we applied antibiotic-loaded bone cements as a spacer. The mean blood loss during initial implantation surgery and operation time both correlated with interval period between PJI and initial implantation significantly (P = 0.028, P = 0.046). For several patients which infection marker was hardly back to normal after spacer implantation, we conservatively introduced an improved combination of bone cement and prosthesis for the second-stage surgery (5.6%). There were six patients needing re-operation, of which three were due to the aseptic loosening of the prosthesis, one developed periprosthetic infection again, and two patients encountered local recurrence and underwent amputation. Two patients were dead from distal metastasis.

Conclusions

A two-stage revision strategy remains effective and standardized methods for PJI patients. Total operation time and blood loss during LSS of osteosarcoma are the main risk factors of early PJI. For the patients without confirmed eradiation of microorganisms, an improved combination of bone cement and prosthesis applied in the second-stage surgery could achieve satisfied functional and oncologic results.

Fracture fixation versus revision arthroplasty in Vancouver type B2 and B3 periprosthetic femoral fractures: a systematic review

INTRODUCTION

Hip arthroplasty (HA) is commonly performed to treat various hip pathologies. Its volume is expected to rise further due to the increasing age of the population. Complication rates are low; however, periprosthetic femoral fractures (PFF) are a rare, albeit serious, complication with substantial economic impact. While current guidelines propose revision with long-stemmed prostheses for all Vancouver B2 and B3 PFF, some recent research papers suggest that open reduction with internal fixation (ORIF) could lead to an equivalent outcome. Our aim was to summarize the evidence, elucidating under which circumstances ORIF leads to a favorable outcome after B2 and B3 PFF compared with revision surgery.

MATERIALS AND METHODS

A systematic literature search was performed to identify studies on patients treated with ORIF and with stem revision after B2 and/or B3 fractures. Extracted information included initial pathology, stem fixation mechanism, bone quality and stem stability at the time of PFF, clinical outcomes, and mortality. Results of individual studies were summarized in a table in lieu of a quantitative data synthesis due to a lack of standardized information.

RESULTS

We identified 14 original research articles including both patients treated with ORIF and with stem revision after B2 and/or B3 PFF. Five studies included statistical comparisons, all were in favor of ORIF or indeterminate. The common lack of rigorous statistical analyses and significant methodological weaknesses made identification of outcome predictors impossible.

CONCLUSION

The choice of treatment modality for PFF depends on fracture, implant, and bone characteristics. Recent data show that successful outcome can be achieved without revising loose stems. ORIF may be a viable option if bone stock is adequate around uncemented or tapered polished stems with an intact cement mantle and the fracture geometry allows stable anatomic reconstruction. Conceptional considerations support this idea, but more data are needed to identify outcome predictors.