A case series of mortality and morbidity in distal femoral periprosthetic fractures

Fix or Replace? Comparable Outcomes with Internal Fixation and Distal Femoral Replacement for Periprosthetic Fractures above Total Knee Arthroplasty

INTRODUCTION

The optimal treatment for periprosthetic fracture (PPfx) around total knee arthroplasty (TKA) remains a topic of debate. Due to its low incidence, comparative studies analyzing arthroplasty and fixation are lacking in the literature. The purpose of this study was to compare the outcomes of distal femoral replacement (DFR) and open reduction and internal fixation (ORIF) for distal femur PPfx.

METHODS

We reviewed a consecutive series of 99 patients who underwent DFR (n = 54) or ORIF (n = 45) for distal femur PPfx. The indications for DFR were reviewed. Fractures were classified based on their relation to the implant using the Su classification. The primary outcome was re-revision, while secondary endpoints included inpatient complications, mortality within the first year, and mechanical complications such as loosening and non-union.

RESULTS

Type 2 fractures were the most prevalent type in both groups (DFR 37 versus ORIF 48.9%), while Type 1 fractures were more commonly treated with ORIF (35.6 versus 16.7%) and Type 3 with DFR (46.3 versus 15.6%) (P = 0.003). The preferred techniques in the ORIF group were plate osteosynthesis (66.7%) and retrograde nailing (31.1%). At a mean follow-up of 4.2 years (range, 1 to 14.1), DFR and ORIF did not demonstrate any difference in revision rates (13 versus 24.4%, P = 0.140) or mortality (3.7 versus 4.4%, P = 0.887). However, more mechanical complications were noted in the ORIF group (22.2 versus 7.4%, P = 0.035).

CONCLUSION

Both distal femoral replacement and open reduction and internal fixation have comparable revision rates, complications, and clinical outcomes when used in supracondylar periprosthetic distal femur fractures. Longer-term studies are needed to assess DFR survivorship as well as outcomes of newer trauma techniques such as nail-plate combinations.

Optimizing periprosthetic fracture management and in-hospital outcome: insights from the PIPPAS multicentric study of 1387 cases in Spain

BACKGROUND

The incidence of all periprosthetic fractures (PPF), which require complex surgical treatment associated with high morbidity and mortality, is predicted to increase. The evolving surgical management has created a knowledge gap regarding its impact on immediate outcomes. This study aimed to describe current management strategies for PPF and their repercussions for in-hospital outcomes as well as to evaluate their implications for the community.

METHODS

PIPPAS (Peri-Implant PeriProsthetic Survival Analysis) was a prospective multicentre observational study of 1387 PPF performed during 2021. Descriptive statistics summarized the epidemiology, fracture characteristics, management, and immediate outcomes. A mixed-effects logistic regression model was employed to evaluate potential predictors of in-hospital mortality, complications, discharge status, and weight-bearing restrictions.

RESULTS

The study encompassed 32 (2.3%) shoulder, 4 (0.3%) elbow, 751 (54.1%) hip, 590 (42.5%) knee, and 10 (0.7%) ankle PPF. Patients were older (median 84 years, IQR 77-89), frail [median clinical frailty scale (CFS) 5, IQR 3-6], presented at least one comorbidity [median Charlson comorbidity index (CCI) 5, IQR 4-7], were community dwelling (81.8%), and had outdoor ambulation ability (65.6%). Femoral knee PPF were most frequently associated with uncemented femoral components, while femoral hip PPF occurred equally in cemented and uncemented stems. Patients were managed surgically (82%), with co-management (73.9%), through open approaches (85.9%) after almost 4 days (IQR, 51.9-153.6 h), with prosthesis revision performed in 33.8% of femoral hip PPF and 6.5% of femoral knee PPF. For half of the patients, the discharge instructions mandated weight-bearing restrictions. In-hospital mortality rates were 5.2% for all PPF and 6.2% for femoral hip PPF. Frailty, age > 84 years, mild cognitive impairment, CFS > 3, CCI > 3, and non-geriatric involvement were candidate predictors for in-hospital mortality, medical complications, and discharge to a nursing care facility. Management involving revision arthroplasty by experienced surgeons favoured full weight-bearing, while an open surgical approach favoured weight-bearing restrictions.

CONCLUSIONS

Current arthroplasty fixation check and revision rates deviate from established guidelines, yet full weight-bearing is favoured. A surgical delay of over 100 h and a lack of geriatric co-management were related to in-hospital mortality and medical complications. This study recommends judicious hypoaggressive approaches. Addressing complications and individualizing the surgical strategy can lead to enhanced functional outcomes, alleviating the economic and social burdens upon hospital discharge. Level of Evidence Level IV case series.

TRIAL REGISTRATION

registered at ClinicalTrials.gov (NCT04663893), protocol ID: PI 20-2041.

Comparative outcomes after treatment of peri-implant, periprosthetic, and interprosthetic femur fractures: which factors increase mortality risk?

Objectives

To compare mortality rates between patients treated surgically for periprosthetic fractures (PPF) after total hip arthroplasty (THA), total knee arthroplasty (TKA), peri-implant (PI), and interprosthetic (IP) fractures while identifying risk factors associated with mortality following PPF.

Design

Retrospective.

Setting

Single, Level II Trauma Center.

Patients/Participants

A retrospective review was conducted of 129 consecutive patients treated surgically for fractures around a pre-existing prosthesis or implant from 2013 to 2020. Patients were separated into 4 comparison groups: THA, TKA, PI, and IP fractures.

Intervention

Revision implant or arthroplasty, open reduction and internal fixation (ORIF), intramedullary nailing (IMN), percutaneous screws, or a combination of techniques.

Main Outcome Measurements

Primary outcome measures include mortality rates of different types of PPF, PI, and IP fractures at 1-month, 3-month, 6-month, 1-year, and 2-year postoperative. We analyzed risk factors associated with mortality aimed to determine whether treatment type affects mortality.

Results

One hundred twenty-nine patients were included for final analysis. Average follow-up was similar between all groups. The overall 1-year mortality rate was 1 month (5%), 3 months (12%), 6 months (13%), 1 year (15%), and 2 years (22%). There were no differences in mortality rates between each group at 30 days, 90 days, 6 months, 1 year, and 2 years (P-value = 0.86). A Kaplan-Meier survival curve demonstrated no difference in survivorship up to 2 years. Older than 65 years, history of hypothyroidism and dementia, and discharge to a skilled nursing facility (SNF) led to increased mortality. There was no survival benefit in treating patients with PPFs with either revision, ORIF, IMN, or a combination of techniques.

Conclusion

The overall mortality rates observed were 1 month (5%), 3 months (12%), 6 months (13%), 1 year (15%), and 2 years (22%), and no differences were found between each group at all follow-up time points. Patients aged 65 and older with a history of hypothyroidism and/or dementia discharged to an SNF are at increased risk for mortality. From a mortality perspective, surgeons should not hesitate to choose the surgical treatment they feel most comfortable performing.

Level of Evidence

Level III.

Optimal surgical treatment for periprosthetic distal femoral fractures after total knee arthroplasty: a Bayesian-based network analysis

BACKGROUND

The surgical methods for periprosthetic distal femoral fractures (PDFFs) after total knee arthroplasty included locking compression plate (LCP), retrograde intramedullary nailing (RIMN), and distal femoral replacement (DFR). However, the optimal treatment remains controversial. We performed a network meta-analysis (NMA) to provide the optimal surgical method for PDFFs.

MATERIALS AND METHODS

Electronic databases, including Embase, Web of Science, Cochrane Library, and PubMed, were searched for studies that compared LCP, RIMN, and DFR for PDFFs. The quality of the included studies was assessed according to the Newcastle-Ottawa scale. Pairwise meta-analysis was performed by Review Manager version 5.4. The NMA was conducted in Aggregate Data Drug Information System software version 1.16.5. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for postoperative complications and reoperations.

RESULTS

A total of 19 studies and 1198 patients were included, of whom 733 for LCP, 282 for RIMN, and 183 for DFR. Pairwise meta-analysis comparing LCP to RIMN and LCP to DFR showed no significant difference in complications and reoperations except that RIMN had a higher risk of malunion comparing to LCP (OR 3.05; 95% CI 1.46-6.34; P = 0.003). No statistically significant effects were found in the NMA of overall complications, infection, and reoperation. However, results of rank probabilities showed that DFR ranked best in overall complications and reoperation, RIMN ranked best in infection but worst in reoperation, and LCP ranked worst in infection and middle in reoperation.

DISCUSSION

We found similar complication rate and reoperation rate between LCP, RIMN, and DFR. The results of rank probabilities favored DFR, and further studies with high-level evidence are expected to verify the optimal surgical method for PDFFs.

LEVEL OF EVIDENCE

Level II; network meta-analysis.

Mortality and clinical outcomes of Vancouver type B periprosthetic femoral fractures : a multicentre retrospective study

AIMS

The objectives of this study were to investigate the patient characteristics and mortality of Vancouver type B periprosthetic femoral fractures (PFF) subgroups divided into two groups according to femoral component stability and to compare postoperative clinical outcomes according to treatment in Vancouver type B2 and B3 fractures.

METHODS

A total of 126 Vancouver type B fractures were analyzed from 2010 to 2019 in 11 associated centres' database (named TRON). We divided the patients into two Vancouver type B subtypes according to implant stability. Patient demographics and functional scores were assessed in the Vancouver type B subtypes. We estimated the mortality according to various patient characteristics and clinical outcomes between the open reduction internal fixation (ORIF) and revision arthroplasty (revision) groups in patients with unstable subtype.

RESULTS

The one-year mortality rate of the stable and unstable subtype of Vancouver type B was 9.4% and 16.4%. Patient demographic factors, including residential status and pre-injury mobility were associated with mortality. There was no significant difference in mortality between patients treated with ORIF and Revision in either Vancouver B subtype. Patients treated with revision had significantly higher Parker Mobility Score (PMS) values (5.48 vs 3.43; p = 0.00461) and a significantly lower visual analogue scale (VAS) values (1.06 vs 1.94; p = 0.0399) for pain than ORIF in the unstable subtype.

CONCLUSION

Among patients with Vancouver type B fractures, frail patients, such as those with worse scores for residential status and pre-injury mobility, had a high mortality rate. There was no significant difference in mortality between patients treated with ORIF and those treated with revision. However, in the unstable subtype, the PMS and VAS values at the final follow-up examination were significantly better in patients who received revision. Based on postoperative activities of daily life, we therefore recommend evision in instances when either treatment option is feasible.Cite this article: Bone Jt Open 2023;4(1):38-46.

Comparison of morbidity-mortality and functional results between implant exchange and internal fixation by plate for periprosthetic femoral fracture in total knee arthroplasty: A 52-case series

INTRODUCTION

Surgical options for periprosthetic femoral fracture in total knee arthroplasty (TKA) are controversial. The present retrospective study compared morbidity, mortality and functional results between implant exchange (group IE) and internal fixation by plate (group IF). The study hypothesis was that implant exchange does not give rise to more complications than plate fixation and that functional results are equivalent.

METHODS

Fifty-two femoral fractures in contact with a TKA implant were studied. The IE and IF groups (n 32 and 20, respectively), were comparable for age, gender and ASA score. Mean age was 80.5 years (range, 53-96 years). Morbidity and mortality were assessed on Clavien score; functional assessment used the KOOS questionnaire.

RESULTS

Mortality was 50% in group IF and 40% in group IE (p=0.4817). One patient was lost to follow-up. Complications were seen in 15 group IF patients (48.4%) versus 5 in group IE (26.3%) (p=0.14760), with infection in 5 (16.1%) and 2 patients (10.5%) respectively (p=0.69475). In both groups, 9 patients (i.e., 28.1% and 40% respectively) showed grade 2 complications (p=1). Revision surgery was performed in 8 grade 3b patients (25%) in the IF group and in 3 (15%) in the IE group (p=1). Mean KOOS score was 40 (range, 20-72) in IF and 65 (range, 50-93) in IE (p=0.0004).

CONCLUSION

Morbidity and mortality were comparable between implant exchange and plate fixation for periprosthetic femoral fracture in TKA. KOOS functional scores were better with implant exchange. Implant exchange may be suited to complex fracture with stable implant.

LEVEL OF EVIDENCE

IV, observational study.

Lower mortality in distal femoral fractures in the presence of a knee arthroplasty: an observational study on 2,725 fractures from the Swedish Fracture Register

BACKGROUND AND PURPOSE

Distal femoral fractures (DFF) in older patients have mortality rates comparable to fractures of the proximal femur. An ageing population combined with an increasing number of patients undergoing total knee arthroplasty (TKA) will make periprosthetic distal femoral fractures (pDFF) more common. We investigated whether a pre-existing TKA influences mortality rates.

PATIENTS AND METHODS

All patients ≥ 60 years registered in the Swedish Fracture Register with a DFF sustained between March 20, 2011 and December 31, 2020 were included. The study cohort comprised 2,725 patients, of which 650 had a pDFF. Unadjusted 90-day and 1-year mortality was estimated via Kaplan-Meier survival curves. A Cox regression model adjusted for age, sex, and treatment modality was used to investigate the association between DFF or pDFF and mortality.

RESULTS

Mean age was 80 years and 82% were females. The most common injury mechanism was a simple fall (75%). The pDFF and DFF group were similar with regards to age, sex, and trauma mechanism. Unadjusted 90-day and 1-year mortality was 11% (95% CI 10-12) and 21% (CI 19-23), respectively. Kaplan-Meier survival analysis demonstrated a slightly lower mortality for pDFFs, especially in patients ≤ 70 years. The Cox regression model showed a lower hazard ratio (HR) for mortality in the pDFF group (HR 0.82, CI 0.71-0.94).

INTERPRETATION

In a large cohort of patients ≥ 60 years with a distal femoral fracture, mortality rates at 90 days and 1 year post-injury were 11% and 21%, respectively. Periprosthetic fractures were associated with a lower mortality.

The value of megaprostheses in non-oncological fractures in elderly patients: A short-term results

INTRODUCTION

The management of both hip and distal femur fractures as well as periprosthetic fractures can be challenging for orthopaedic surgeons. The use of megaprosthetic implants could provide substantial advantages in elderly population affected by complex fractures. The aim of the study was to evaluate the effectiveness of megaprosthetic implants for treating hip and distal femur fractures as well as periprosthetic fractures in elderly.

MATERIAL AND METHODS

From January 1st 2015 to December 31st 2019, patients treated for proximal or distal femoral fractures with severe bone loss or failure of previous surgery were retrospectively reviewed. Patients were divided into two group based on diagnosis: proximal femur fractures (group A) and distal femur fractures (group B). Subsequently, patients underwent hip (group A) or knee (group B) megaprosthesis. Self-assessed questionnaires were administered to all patients pre and postoperatively. Primary outcome was the Activity Daily Living. Secondary outcomes were: Instrumental Activity Daily Living, Short Form-12, Oxford knee or hip score, complications. Charlson score, Harris classification for hip or Anderson Orthopaedic Research Institute score and complication were recorded. All patients underwent a radiological follow up to rule out implant loosening and mobilization. Pre and postoperative functional score comparisons in each group were undertaken. Significance was set p ≤ 0.05.

RESULTS

Twelve patients were finally included in the study. There were 6 male and 6 females, the mean age was 72,9 years old (± 7,4); the mean BMI was 29,8 points (± 4.5). The mean follow-up was 2.9 years (± 1.4). No differences could be found between pre and postoperative evaluation in each group. No aseptic loosening, dislocation, mobilization or radiolucency were recorded during the follow-up. In group A, two surgical site infections (2/6 patients) and one pneumonia (1/6 patients) were recorded. In group B, two surgical site infections occurred (2/6 patients). All patients were treated by antimicrobial oral therapy with complete regression.

CONCLUSION

The use of hip and knee megaprosthetic implants in traumatology is a safe and viable option in elderly patients.

Cost-effectiveness of fixation versus arthroplasty for geriatric distal femur fractures

INTRODUCTION

Geriatric distal femur fractures are challenging to treat. The high mortality rate associated with a loss of mobility in this population has led some authors to compare distal femur fractures to femoral neck fractures with respect to the importance of rapidly regaining mobility in the geriatric population. Acute distal femur replacement has been advocated by some as a preferred treatment over internal fixation because arthroplasty may facilitate a more rapid return to a patient's baseline mobility level. The purpose of this study was to systematically review the literature on the costs and outcomes of fixation and arthroplasty in the geriatric distal femur fracture population and to employ decision modeling techniques to generate evidence-based treatment recommendations.

METHODS

A systematic literature review of clinical studies published since 2000 was conducted to synthesize the available data on outcomes, reoperation rates, and mortality rates after fixation or arthroplasty for distal femur fractures in patients with an average age greater than 70 years. A Markov decision analysis model was created. Costs, health state utilities, reoperation rates, and mortality rates were derived from the systematic literature review and publicly available data. The model was analyzed via probabilistic statistical analysis as well as sensitivity analyses with a willingness-to-pay threshold set at $100,000 per QALY and a 5-year time horizon.

RESULTS

From a US societal perspective, fixation was associated with a greater quality of life benefit (2.44 QALYs vs. 2.34 QALYs) and lower cost ($25,556 vs. $65,536) compared with distal femur replacement for geriatric distal femur fractures. Probabilistic analysis demonstrated that 82 in 100 model outcomes favored fixation over arthroplasty and 18 in 100 model outcomes favored distal femur replacement. Sensitivity analyses demonstrated that this result was robust to small deviations in the cost and functional outcome variables in the model.

CONCLUSION

Compared to distal femur replacement, ORIF is likely to be a more cost-effective treatment for distal femur fractures in the geriatric patient population, though this recommendation is tempered by the relatively low quality of evidence available on the comparative functional outcomes of these treatments.

Beyond Hip Fractures: Other Fragility Fractures' Associated Mortality, Functional and Economic Importance: A 2-year-Follow-up

Background

Hip fractures are well researched in orthogeriatric literature. Equivalent investigations for fragility-associated periprosthetic and periosteosynthetic femoral, ankle joint, pelvic ring, and rib fractures are still rare.

The purpose of this study was to evaluate mortality, functional outcome, and socioeconomic parameters associated to the upper-mentioned fragility fractures prospectively in a 2-year follow-up.

Methods

Over the course of a year, all periprosthetic and periosteosynthetic femoral fractures (PPFF), ankle joint fractures (AJ), pelvic ring fractures (PR), and rib fractures (RF), that were treated on a co-managed orthogeriatric ward, were assessed. Parker Mobility Score (PMS), Barthel Index (BI), place of residence, and care level were recorded. After 2 years, patients and/or relatives were contacted by mailed questionnaires or phone calls in order to calculate mortality and reevaluate the mentioned parameters.

Results

Follow-up rate was 77.7%, assessing 87 patients overall. The relative mortality risk was significantly increased for PR (2.9 (95% CI: 1.5–5.4)) and PPFF (3.5 (95% CI: 1.2–5.8)) but not for RF (1.5 (95% CI: 0.4–2.6)) and AJ (2.0 (95% CI: 0.0–4.0)). Every fracture group except AJ showed significantly higher BI on average at follow-up. PMS was, respectively, reduced on average for PR and RF insignificantly, but significantly for PPFF and AJ in comparison to pre-hospital values. 10.0–27.3% (each group) of patients had to leave their homes permanently; care levels were raised in 30.0–61.5% of cases.

Discussion

This investigation provides a perspective for further larger examinations. PR and PPFF correlate with significant increased mortality risk. Patients suffering from PPFF, PR, and RF were able to significantly recover in their activities of daily living. AJ and PPFF conclude in significant reduction of PMS after 2 years.

Conclusion

Any fragility fracture has its impact on mortality, function, and socioeconomic aspects and shall not be underestimated. Despite some fractures not being the most common, they are still present in daily practice.

A Comparison of Risks and Benefits Regarding Hip Arthroplasty Fixation

Since the field-changing invention of noncemented hip arthroplasty fixation in the 1980s, noncemented fixation has been progressively replacing cemented fixation. However, analyses of fixation frequencies reveal new patterns in cement versus noncemented preferences. Although cementation is again gaining ground in the United States, noncemented models remain the dominant fixation mode, seen in more than 90% of all hip arthroplasties. This stark preference is likely driven by concerns regarding implant durability and patient safety. Although advances in surgical techniques, intensive perioperative care, and improved instrument have evolved in both methods, data from large arthroplasty registries reveal shifting risks in contemporary hip arthroplasty, calling the use of noncemented fixation into question. Varying risk profiles regarding sex, age, or health comorbidities and morphological and functional differences necessitate personalized risk assessments. Furthermore, certain patient populations, based on the literature and data from large registries, have superior outcomes from cemented hip arthroplasty techniques. Therefore, we wanted to critically evaluate the method of arthroplasty fixation in primary hip arthroplasties for unique patient populations.

Review of patient-reported outcomes in periprosthetic distal femur fractures after total knee arthroplasty: a plate or intramedullary nail?

Purpose

This study reviewed the literature regarding the patient-reported treatment outcomes of using either open reduction and internal fixation (ORIF) with a plate and screw system or intramedullary nail (IMN) fixation for periprosthetic distal femur fractures around a total knee arthroplasty.

Methods

A total of 13 studies published in the last 20 years met the inclusion criteria. The studies included 347 patients who were allocated to ORIF (n = 249) and IMN (n = 98) groups according to the implants used. The primary outcome measures were the Knee Society Score or the Western Ontario and McMaster Universities osteoarthritis index. The secondary outcome measures included knee range of motion and the rates of complications, including non-union, malunion, infection, revision total knee arthroplasty, and reoperation. Statistical significance was set at P < 0.05.

Results

The mean Knee Society Scores of ORIF and IMN groups were 83 and 84, respectively; the mean postoperative range of motion of the knee were 99° and 100°, respectively (P < 0.05); the non-union rates were 9.4 and 3.8%, respectively (P > 0.05); the malunion rates were 1.8 and 7.5%, respectively (P < 0.05); surgical site infection rates were 2 and 1.3%, respectively (P > 0.05); the reoperation rates were 9.6 and 5.1%, respectively (P > 0.05); and revision rates of total knee arthroplasty were 2 and 1%, respectively (P > 0.05).

Conclusion

Based on the patient-reported outcome assessments, both ORIF with a plate and screw system and IMN fixation are well-accepted techniques for periprosthetic distal femur fractures around a TKA, and they produce similar functional outcomes.

Early complications and reoperation rates are similar amongst open reduction internal fixation, intramedullary nail, and distal femoral replacement for periprosthetic distal femur fractures: a systematic review and meta-analysis

BACKGROUND

Our purpose was to perform a systematic review and meta-analysis to evaluate complication and revision rates for periprosthetic distal femur fractures (PPDFF) treated with: (1) ORIF using periarticular locking plates (ORIF), (2) retrograde intramedullary nail (IMN), and (3) distal femoral replacement (DFR).

METHODS

Systematic review of the literature was performed to identify eligible studies (N = 52). Identified treatment groups were: ORIF (N = 1205 cases), IMN (N = 272 cases), and DFR (N = 353 cases). Median follow-up was 30 months (range 6-96 months). Primary outcomes were: (1) major complication rates and (2) reoperation rates over the follow-up period. Secondary outcomes were incidence of deep infection, periprosthetic fracture, mortality over the follow-up period, 1-year mortality, non-union, malunion, delayed union, and hardware failure. Data for primary and secondary outcomes were pooled and unadjusted analysis was performed. Meta-analysis was performed on subset of individual studies comparing at least two of three treatment groups (N = 14 studies). Odds-ratios and their respective standard errors were determined for each treatment group combination. Maximum likelihood random effects meta-analysis was conducted for primary outcomes.

RESULTS

From the systematic review, major complication rates (p = 0.55) and reoperation rates (p = 0.20) were not significantly different between the three treatment groups. DFR group had a higher incidence of deep infection relative to IMN and ORIF groups (p = 0.03). Malunion rates were higher in IMN versus ORIF (p = 0.02). For the meta-analysis, odds of major complications were not significantly different between IMN versus DFR (OR 1.39 [0.23-8.52]), IMN versus ORIF (OR 0.86 [0.48-1.53]), or the ORIF versus DFR (OR 0.91 [0.52-1.59]). Additionally, odds of a reoperation were not significantly different between IMN versus DFR (OR 0.59 [0.08-4.11]), IMN versus ORIF (OR 1.26 [0.66-2.40]), or ORIF versus DFR (OR 0.91 [0.51-1.55]).

CONCLUSIONS

There was no difference in major complications or reoperations between the three treatment groups. Deep infection rates were higher in DFR relative to internal fixation, malunion rates were higher in IMN versus ORIF, and periprosthetic fracture rates were higher in DFR and IMN versus ORIF.