Total hip arthroplasty following the failure of intertrochanteric nailing: First implant or salvage surgery?

Risk factors for perioperative blood transfusion in total hip arthroplasty: a meta-analysis

OBJECTIVE

The present study assessed and synthesized the potential risk factors for perioperative blood transfusion in total hip arthroplasty from various studies through Meta-analysis.

METHODS

We systematically searched for relevant studies in databases including Web of Science, PubMed, Embase, and Cochrane Library from the time of database creation to 1 February 2025 and included all observational studies exploring perioperative transfusion risk factors in patients undergoing total hip arthroplasty. All included studies were assessed for quality using the Newcastle-Ottawa Scale (NOS) scale. Data were analyzed using Stata 15 software.

RESULTS

A total of 18 articles (n = 424,158) were included, meta-analysis results suggest that increased intraoperative bleeding [OR = 1.13, 95%CI (1.02, 1.24)], increased postoperative drainage [OR = 2.24, 95%CI (1.24, 4.83)], body mass index ≤ 18.5 [OR = 1.10, 95%CI (1.02, 1.20)], preoperative anemia [OR = 1.82, 95%CI (1.62, 2.03)], age ≥ 80 [OR = 1.49 95%CI(1.21, 1.83)], female [OR = 1.92, 95%CI (1.71, 2.15)], ASA class ≥ 3 [OR = 2.06, 95%CI (1.63, 2.61)] in patients with total hip arthroplasty (THA) increases the incidence of perioperative blood transfusion.

CONCLUSION

The results of the current study suggest that increased intraoperative bleeding, increased postoperative drainage, low body mass index (≤ 18.5), preoperative anemia, advanced age (≥ 80 years), female gender, and high ASA classification (≥ 3) were significantly associated with the likelihood of needing blood transfusion. These findings highlight the importance of preoperative risk assessment and perioperative management strategies to reduce the need for blood transfusion and improve patient outcomes.

Conversion Total Hip Arthroplasty after Sliding Hip Screw and Cephalomedullary Nail Failures: A Systematic Comparative Review and Meta-analysis

With the exception of revision osteosynthesis, conversion total hip arthroplasty (CTHA) following sliding hip screw (SHS) and cephalomedullary nail (CMN) failure in intertrochanteric fractures (ITF) is the most commonly used treatment option. This review determined the relative risk of medical and orthopedic complications, including periprosthetic femoral fractures (PFF), following CTHA in failed SHS and CMN fixation of ITF, as well as the Harris hip score (HHS). Major electronic databases were searched for studies and reports on CTHA after SHS and CMN fixation failures in ITF. To assess the risk of bias, the studies were analyzed using the Joanna Briggs Institute critical appraisal tool for cohort studies. Three studies pooled 327 cases and 353 cases of CTHA from failed CMN and SHS in ITF. The relative risk of medical and orthopedic complications and PFF in the SHS group as compared to the CMN group was 0.87 [0.39, 1.90], 1.64 [1.18, 2.29], and 1.92 [0.81, 4.56], respectively. The mean difference in HHS was -0.72 [-1.47, 0.02] between failed SHS and CMN groups. The included studies were of retrospective study design with a more than 20% loss of follow-up and a high risk of bias. There is 64% more risk of orthopedic complications with CTHA in SHS failures than CMN failures. There is no difference in relative risk of medical complications and PFF between CTHA in both SHS and CMN failure. After CTHA, the benefits in function are similar in both groups.

Optimizing Stem Length in Conversion Total Hip Arthroplasty: An Expanded Finite Element Analysis

Background/Objectives: Stress concentration around distal screw-removal holes confers a major risk for periprosthetic fractures following conversion total hip arthroplasty (cTHA) for intertrochanteric femoral fractures. Optimal stem-selection criteria and guidelines for cTHA can improve clinical outcomes. We determined the influence of the cementless stem length on the stress distribution around distal screw-removal holes. Methods: For the finite element analysis, institutional data from preoperative CT scans of contralateral femurs of patients who underwent THA were used. To replicate the post-nail-removal state, we used 3D registration of standard triangulated language data of the intramedullary nail as an unused material to simulate distal screw-removal holes, located 135 mm from the proximal end of the intramedullary nail. Cementless stems of 130, 140, 150, and 160 mm were individually registered using STL data, and cTHA models were constructed accordingly. Using simulations under load conditions representing normal walking and stair climbing, the mean and maximum equivalent stress values around the distal screw-removal holes were calculated. For multiple comparisons, repeated-measures ANOVA with Bonferroni correction was employed. Results: Compared to the 130 mm stem, the 150 mm and 160 mm stems similarly reduced the maximum equivalent stress around the distal screw-removal holes, although the 140 mm stem showed no significant difference with other stems. Conclusions: A ≥150 mm stem length reliably mitigated stress concentration around distal screw-removal holes post-cTHA; it is the optimal choice for balancing effectiveness and risk of complications and may contribute to improved long-term clinical outcomes. This study provides practical evidence for stem selection in cTHA and offers valuable insights for future treatment guidelines.

Key Decision-Making in Post-Failed Internal Fixation of Intertrochanteric Fractures Hip Arthroplasty: A Multicenter Retrospective Study on Fracture Healing's Impact on Femoral Component Selection

PURPOSE

Following failed internal fixation of intertrochanteric fractures (FIF-ITF), the decision to use a long-stem or standard-stem femoral implant in hip arthroplasty is still debated. This study aimed to explore how the healing status of fractures after FIF-ITF failure affects the choice of femoral stem and clinical outcomes.

METHODS

Our retrospective cohort study reviewed 105 cases of patients with FIF-ITF who underwent hip arthroplasty at three tertiary Grade A hospitals between December 2012 and December 2022. We compared the clinical outcomes between patients with healed and unhealed fractures, focusing on the selection of femoral stems in relation to proximal medial support and the healing status of the greater trochanter. The primary outcomes measured were functional results, operative time, blood loss, and incidence of complications. A subgroup analysis was conducted to further evaluate the influence of the proximal medial buttress and greater trochanteric healing on femoral stem selection. Statistical analysis included binary and ordinal logistic regression to identify factors influencing the choice of femoral stems. Additionally, a decision tree model was developed to visually represent and explore the relationship between fracture healing status and the selection of femoral components.

RESULTS

The study included 38 patients with healed fractures and 67 patients with unhealed fractures. Patients in the healed group predominantly chose standard stems and experienced better functional outcomes (p < 0.001, p = 0.002). In contrast, the unhealed group preferred long stems, resulting in longer surgical durations and increased blood loss (p = 0.008, p < 0.001). Binary logistic regression analysis revealed that nonunion of the proximal femoral medial buttress was an independent risk factor for long stems (p < 0.0001, OR = 10.402).

CONCLUSION

The selection of femoral prostheses following FIF-ITF is influenced by the fracture healing status, particularly the presence of proximal femoral medial buttress. The decision tree model suggested that long-stem prostheses are more appropriate when there is inadequate fracture healing and the proximal femoral medial buttress is absent.

Stress Analysis in Conversion Total Hip Arthroplasty: A Finite Element Analysis on Stem Length and Distal Screw Hole

Background/Objectives: Proximal femoral fractures are particularly common in older adults, and cases requiring conversion to total hip arthroplasty may arise because of treatment failure or osteoarthritis. Fractures around the distal screw removal holes can be problematic. This study aimed to analyze the relationship between stem length and femoral stress distribution to determine the optimal stem length. Methods: A finite element analysis simulation was conducted using pre-existing femoral computed tomography data, an intramedullary nail, and three types of stems of varying lengths. Loads simulating normal walking and stair climbing were applied, and the average and maximum equivalent stresses were measured on both the medial and lateral sides of the distal screw removal hole for each stem length. Statistical analysis was then performed to evaluate the stress distributions. Results: The average stress around the distal screw removal hole tended to decrease as stem length increased. The maximum stress was significantly lower with the 160-mm stem, which provides a 40-mm bridging length, compared to the 120-mm and 130-mm stems, where the stem tip aligned with or only slightly extended past the distal screw removal hole (bridging lengths of 0 mm and 10 mm, respectively). Conclusions: In conversion hip total arthroplasty following proximal femoral fractures, using a sufficiently long stem can help avoid stress concentration around the distal screw removal hole, thereby potentially reducing the risk of periprosthetic fractures.

Conversion hip arthroplasty for failed nailing of intertrochanteric fracture: Reflections on some important aspects

In this editorial, I present my comments on the article by Solarino et al. Conversion hip arthroplasty, which is an optional salvage procedure performed following unsuccessful fixation of intertrochanteric femur fractures in elderly patients, entails more complex processes and higher rates of operative complications than primary arthroplasty. Hence, it is important to consider the appropriateness of the primary treatment choice, as well as the adequacy of nailing fixation for intertrochanteric fractures. This article briefly analyzes the possible factors contributing to the nailing failure of intertrochanteric fractures and attempts to find corresponding countermeasures to prevent fixation failures. It also analyzes the choice of treatment between nailing fixation and primary arthroplasty for intertrochanteric fractures.