Risk analysis and clinical outcomes of intraoperative periprosthetic fractures: a retrospective study of 481 bipolar hemiarthroplasties

Age as a Risk Factor for Intraoperative Periprosthetic Femoral Fractures in Cementless Hip Hemiarthroplasty for Femoral Neck Fractures: A Retrospective Analysis

Background

Understanding the risk factors and outcomes of intraoperative periprosthetic femoral fractures (IPFF) during hip arthroplasty is crucial for appropriate perioperative management. Previous studies have identified risk factors for IPFF in total hip arthroplasty patients, but data for hip hemiarthroplasty (HA) is lacking. The aim of this study was to determine the age associated with increased rates of IPFF in patients undergoing HA.

Methods

We retrospectively reviewed patients aged 65 years and above who underwent a cementless HA for a displaced femoral neck fracture and had a minimum of 1-year follow-up. Patients were stratified into five age groups (65-79, 80-84, 85-89, 90-94, and ≥ 95 years) and further divided into two subgroups (under 95 years and 95 years or older). The presence, location, and treatment of IPFF, as well as the effect of IPFF on the postoperative weight-bearing status, were compared between groups. A multivariate logistic regression was also performed. A total of 1,669 met the inclusion criteria and were included in the study.

Results

The rates of IPFF were significantly higher for patients 95 years or older (p = 0.030). However, fracture location (greater trochanter fractures, p = 0.839; calcar fractures, p = 0.394; and femoral shaft fractures p = 0.110), intraoperative treatment (p = 0.424), and postoperative weight-bearing status (p = 0.229) were similar between the groups. While mortality and nonorthopedic-related readmissions were significantly higher for patients 95 years or older, orthopedic-related readmissions (p = 0.148) and revisions at the latest follow-up (p = 0.253) were comparable between groups. In a regression analysis, age over 95 years (odds ratio, 2.049; p = 0.049) and body mass index (odds ratio, 0.935; p = 0.016) were independently associated with IPFF.

Conclusions

The findings of this study suggest that age over 95 years is a significant, independent risk factor for IPFF in patients undergoing cementless HA. Although we were unable to show an impact on perioperative outcomes and orthopedic complications, when operating on patients 95 years or older, surgeons should be aware of the increased risk of IPFF and consider the use of stem designs and fixation types associated with decreased IPFF rates.

Risk factors for intraoperative femoral fractures in cementless bipolar hip arthroplasty for femoral neck fracture in multicenter: The TRON group study

BACKGROUND

Intraoperative femoral fractures are more common in cementless bipolar hip arthroplasty (BHA) for displaced femoral neck fractures than they are in cemented BHA and remain one of the major concerns. This study aimed to investigate the risk factors for intraoperative femoral fractures in cementless BHA.

METHODS

The study included 1,392 patients who underwent cementless BHA for displaced femoral neck fractures from January 2015 to December 2019 in 14 hospitals of the Trauma Research Group. They were divided into two groups according to the presence or absence of intraoperative femoral fractures, and factors associated with intraoperative fractures were statistically examined.

RESULTS

Forty (2.9 %) intraoperative and 28 (2.0 %) postoperative, totally 68 (4.9 %) femoral fractures occurred. The mean age of the patients, presence of opposite-side proximal femoral fracture, approach, and cementless stem design were significantly different between the two groups (P < 0.05). The logistic regression analysis model showed that a fully HA-coated stem (odds ratio, 4.12; 95 % confidence interval, 1.43-11.9) was an independent factor associated with intraoperative femoral fractures.

CONCLUSION

This study investigated the risk factors associated with intraoperative fractures and showed that fully HA-coated stems were an independent factor associated with intraoperative femoral fractures. Surgeons should be cautious in the early stages of introducing fully HA-coated stems.

The Effect of Cerclage Banding Distally to a Clamshell Fracture Pattern in Total Hip Arthroplasty-A Biomechanical Study

OBJECTIVES

As currently there is no existing biomechanical work on the topic of interest, the aim of the current study was to investigate the effect of cerclage banding distally to an intraoperatively occurring proximal periprosthetic femoral clamshell fracture versus a non-fractured femur after total hip arthroplasty.

METHODS

A diaphyseal anchoring stem was implanted in twenty paired human cadaveric femora, assigned to a treatment and a control group. In the treatment group, each specimen was fitted with a cerclage band placed 3 mm distally to a clamshell fracture, created with an extent of 40% of the anchoring length of the stem. The resulting fragment was not treated further. The contralateral specimens were left with the stems without further fracture creation or treatment. All constructs were tested under progressively increasing cyclic axial loading until failure. Relative bone-implant movements were monitored by motion tracking.

RESULTS

Number of cycles and the corresponding load at stem loosening, defined as 1 mm displacement of the stem along the shaft axis, were 31,417 ± 8870 and 3641.7 ± 887 N in the control group, and 26,944 ± 11,706 and 3194.4 ± 1170.6 N in the treatment group, respectively, with no significant differences between them, p = 0.106.

CONCLUSION

From a biomechanical perspective, cerclage banding distally to an intraoperative clamshell fracture with an extent of 40% of the anchoring length of the stem demonstrated comparable resistance against hip stem loosening versus a non-fractured femur. It may therefore represent a valid treatment option to restore the full axial stability of a diaphyseal anchoring stem. In addition, it may be considered to keep the medial wall fragment unfixed, thus saving operative time and minimizing associated risks.

Cementless femoral stem revision in total hip arthroplasty: The periprosthetic clamshell fracture. A biomechanical investigation

To biomechanically evaluate the stability of a diaphyseal anchored, cementless stem in presence of a proximal periprosthetic femoral medial wall defect compared to the stability of the same stem in an intact femur. Twenty-two paired human cadaveric femora were pairwise assigned either to a fracture group, featuring a proximal medial wall defect involving 40% of the stems medial anchorage distance, or a control group with native specimens. The specimens were tested under a monotonically increasing cyclic axial loading protocol. Load, cycles, and multiples of the respective body weight at implant loosening was measured. Mean initial stiffness was 2243.9 ± 467.9 N/mm for the intact group and 2190.1 ± 474.8 N/mm for the fracture group. Mean load to loosening in the intact group was 3210.5 ± 1073.2 N and 2543.6 ± 576.4 N in the fracture group, with statistical significance. Mean cycles to loosening in the intact group were 27104.9 ± 10731.7 and 20431.5 ± 5763.7 in the fracture group, with statistical significance. Mean multiples of the resulting body weight at loosening in the intact group was 548.3 ± 158.5% and 441.4 ± 104% in the fracture group, with statistical significance. A medial wall defect involving 40% of the medial anchorage distance significantly decreases the axial stability of a diaphyseal anchored stem. However, mechanical failure occurred beyond physiological stress. At loosening rates of about 4 multiples of the body weight in the fracture group, a "safe zone" remains of a 0.5-fold body weight for maximum loads and twofold body weights for average loads.

Treatment of Chronic Femoral Neck Fracture With Cemented Bipolar Hemiarthroplasty and Management of Intraoperative Fracture With Cerclage Cabling

We cover the operative treatment of a neglected chronic femoral neck fracture nonunion treated at 6 months. We begin with a description of the case and concomitant injuries. The operative portion includes the direct lateral approach with the patient in lateral decubitus position, exposure of the fracture site, osteotomy of the neck, debridement of the nonunion site, broaching, trialing, recognition and treatment of an intraoperative proximal femur fracture using cerclage cabling above and below the lesser trochanter, cementation of final components, and reduction. We conclude with the patient's radiographs at 2 weeks and clinical outcome at 6-week follow-up.

Effectiveness of prophylactic double-looped wiring in cementless Hip arthroplasty: A biomechanical study in osteoporotic bone model using impaction simulation system

BACKGROUND

Periprosthetic femoral fracture (PFF) is well-known complication in cementless hip arthroplasty (HA), especially in the elderly with osteoporosis. To prevent intraoperative PFFs during HA, prophylactic cerclage wiring on the calcar area during femoral broaching and implant insertion is recommended. However, biomechanical data on the benefits of cerclage wiring in osteoporotic bone during impaction are limited and controversial. This study aimed to assess the efficacy of prophylactic double-looped cerclage wiring (PDLCW) during femoral broaching in the osteoporotic bone model with an impaction simulation system.

METHODS

Fifteen osteoporotic femur models were prepared and allocated to three groups; control group (no cerclage), PW group (received PDLCW), and CC+PW group (prepared as having calcar crack and received PDLCW). All femurs were broached under impaction force that sequentially increased until the visible fracture or calcar crack propagation was visible. The primary outcomes were mallet impaction force (MIF-CF) and mallet velocity (MV-CF) at the time of calcar fracture. The secondary outcomes were calcar fracture pattern and subsidence during calcar fracture (S-CF).

RESULTS

PW group showed a significant increase in average MIF-CF, by 40.4% and 120.2% (p<0.001) compared to the control and CC+PW groups, respectively. The average MV-CF in PW group was also significantly greater, 13.1% and 64.6% (p<0.001), compared to the control and CC+PW groups, respectively. Control group revealed significantly greater incidence of complete calcar fracture (60% vs. 0% vs. 0%, p = 0.024), and the highest S-CF compared to those in the PW and CC+PW groups (10.6 ± 6.0 mm, 6.7 ± 4.4 mm, and 1.3 ± 2.0 mm, p = 0.020).

CONCLUSIONS

This study showed that PDLCW significantly improved hoop stress resistance by increasing the calcar fracture threshold related to mallet impaction, decreasing the risk of complete calcar fracture.

A comparison between Austin-Moore and Corail prosthesis regarding intraoperative periprosthetic femur fractures in hip hemiarthroplasty

Hip hemiarthroplasty is considered the treatment of choice for displaced femoral neck fractures in elderly less active patients. One important complication of this procedure is an intraoperative periprosthetic femur fracture (IPF), which may lead to poor functional outcome and may increase morbidity and mortality. Our primary aim in this study is to compare between Austin-Moore and Corail prosthesis regarding IPFs. Our secondary aim is to assess patient and surgical technique related risk factors for the development of this complication. Inclusion criteria included patients older than 65 years of age who had a displaced femoral neck fracture and were operated for hip hemiarthroplasty between the years 2014-2018. Patient-specific data was collected retrospectively including age, gender, comorbidities, pre-injury ambulatory status, duration of surgery, surgical approach, use of Austin-Moore or Corail prosthesis, surgeon's experience and type of anesthesia applied. In addition, radiographs were reviewed for measurement of calcar to canal ratio (CDR) and classification of Dorr canal type. 257 patients with an average age of 83.7 years were enrolled in the study. 118 patients (46%) were treated with an Austin-Moore prosthesis, while 139 (54%) were treated with a Corail prosthesis. A total of 22 patients (8.6%) had intraoperative fractures. Fracture prevalence was significantly higher in the Corail group compared with the Austin-Moore group (12.2% vs. 4.2%, p = 0.025). The majority of patients had a Dorr A type femoral canal, while the rest had Dorr B type canal (70% vs. 30%). There was no difference in fracture prevalence between Dorr A and B canal type patients. We didn't find any significant risk factor for developing an IPF, neither patient wise (age, gender, and comorbidities) nor surgical technique related (surgical approach, type of anesthesia, and surgeon's experience). Intraoperative periprosthetic fracture prevalence was significantly higher in the Corail patient group compared with the Austin-Moore group. This may be an important advantage of the Austin-Moore prosthesis over the Corail prosthesis.

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.

Proximal Femur Responses to Sequential Therapy with Abaloparatide Followed by Alendronate in Postmenopausal Women with Osteoporosis by 3D Modeling of Hip DXA

Previous subgroup analyses from the ACTIVE trial in women with postmenopausal osteoporosis (NCT01343004) using three‐dimensional (3D)‐processing of dual X‐ray absorptiometry (DXA) scans indicated greater increases in total hip cortical volumetric bone mineral density (Ct.vBMD) and estimated indices of hip strength following 18 months of abaloparatide (ABL) versus placebo or teriparatide. The current post hoc analyses describe hip 3D‐DXA data for ACTIVExtend (NCT01657162), in which 18 months of ABL followed by 24 months of alendronate (ABL/ALN) increased hip and spine areal BMD (aBMD) and reduced fracture risk versus placebo (PBO) followed by ALN (PBO/ALN). In an ACTIVExtend subgroup (ABL/ALN, n = 204; PBO/ALN, n = 202), hip DXA scans retrospectively underwent 3D modeling via 3D‐Shaper software. Changes from baseline in cortical and trabecular compartments were calculated for total hip and hip subregions (femoral neck, trochanter, and shaft). Estimated strength indices comprising cross‐sectional moment of inertia, section modulus, and buckling ratio were calculated for each hip subregion. Correlations between bone turnover marker levels at the time of alendronate initiation and subsequent BMD gains with alendronate were also investigated within each group. Total hip trabecular and cortical 3D‐DXA parameters increased from baseline in both groups (all p < 0.001), with greater average increases for ABL/ALN versus PBO/ALN (trabecular vBMD: 10.87% versus 4.3%; cortical thickness: 2.32% versus 1.14%; Ct.vBMD: 3.41% versus 1.86%; cortical surface BMD: 5.82% versus 3.0%; all p < 0.001). Strength indices in the ABL/ALN group improved in all subregions versus baseline (all p < 0.0001) and versus PBO/ALN (all p < 0.02). In the ABL/ALN group, collagen type I N‐terminal propeptide (P1NP) levels at the time of alendronate initiation correlated with subsequent percent changes in all 3D‐DXA parameters with 24 months of alendronate therapy. In conclusion, sequential ABL/ALN or PBO/ALN treatment improves trabecular and cortical 3D‐DXA parameters at the hip, as well as strength indices of hip subregions, with greater increases with ABL/ALN versus PBO/ALN. © 2022 Radius Health, Inc. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Risk factors for intraoperative greater trochanteric fractures in hemiarthroplasty for intracapsular femoral neck fractures

Purpose

Hemiarthroplasty is widely accepted as the treatment of choice in elderly patients with a displaced intracapsular femoral neck fracture. Intraoperative greater trochanteric fractures thwart this successful procedure, resulting in prolonged recovery, inferior outcome, and increased risk of revision surgery. Hence, this study analyzed factors potentially associated with an increased risk for intraoperative greater trochanteric fracture.

Methods

This retrospective study included 512 hemiarthroplasties in 496 patients with a geriatric intracapsular femoral neck fracture from July 2010 to March 2020. All patients received the same implant type of which 90.4% were cemented and 9.6% non-cemented. Intra- and postoperative radiographs and reports were reviewed and particularly screened for greater trochanteric fractures.

Results

Female patients accounted for 74% and mean age of the patients was 82.3 (± 8.7) years. 34 (6.6%) intraoperative greater trochanteric fractures were identified. In relation to patient-specific factors, only a shorter prothrombin time was found to be significantly associated with increased risk of intraoperative greater trochanteric fracture (median 96%, IQR 82–106% vs. median 86.5%, IQR 68.8–101.5%; p = 0.046). Other factors associated with greater trochanteric fracture were a shorter preoperative waiting time and changes in perioperative settings. Outcome of patients with greater trochanteric fracture was worse with significantly more surgical site infection requiring revision surgery (17.6% vs. 4.2%, p = 0.005).

Conclusion

Prolonged prothrombin time, a shorter preoperative waiting time, and implementing new procedural standards and surgeons may be associated with an increased risk of a greater trochanteric fracture. Addressing these risk factors may reduce early periprosthetic infection which is strongly related to greater trochanteric fractures.

Hemiarthroplasty for Femoral Neck Fractures: Does Surgeon Subspecialty Affect Perioperative Outcomes?

OBJECTIVES

To determine if surgeon subspecialty training affects perioperative outcomes for displaced femoral neck fractures treated with hemiarthroplasty.

DESIGN

Retrospective comparative study.

SETTING

One health system with 2 hospitals (Level I and Level III trauma centers).

PATIENT AND PARTICIPANTS

Patients who were treated with hemiarthroplasty for displaced femoral neck fractures between October 2012 and September 2017.

OUTCOME MEASURES

Leg length discrepancy, femoral offset, estimated blood loss (EBL), incidence of blood transfusion, time to surgery, operative time, and length of stay. Data were analyzed based on the treating surgeon's subspecialty training [arthroplasty (A), trauma (T), other (O)]. Hierarchical regression was used to compare the groups and control for confounding variables.

RESULTS

A total of 292 patients who received hemiarthroplasty for displaced femoral neck fractures were included (A = 158; T = 73; O = 61). Surgeon subspecialty had a statistically significant effect on operative time, with arthroplasty surgeons completing the procedure 9.6 minutes faster than trauma surgeons and 17.7 minutes faster than other surgeons (P < 0.01; ΔR = 0.03). Surgeon subspecialty did not significantly affect other outcomes, including leg length discrepancy (P = 0.26), femoral offset (P = 0.37), EBL (P = 0.10), incidence of transfusion (P = 0.67), time to surgery (P = 0.10), or length of stay (P = 0.67).

CONCLUSIONS

This study demonstrates that arthroplasty-trained surgeons perform hemiarthroplasty slightly faster than other subspecialists, but subspecialty training does not affect other perioperative outcomes, including leg length discrepancy, femoral offset, EBL, transfusion rate, time to surgery, or length of stay. This suggests that hemiarthroplasty can be adequately performed by various subspecialists, and deferring treatment to an arthroplasty surgeon might not have a clinically significant benefit in the perioperative period.

LEVEL OF EVIDENCE

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