Periprosthetic fractures around loose femoral components

How Often Do Complications and Mortality Occur After Operatively Treated Periprosthetic Proximal and Distal Femoral Fractures? A Register-based Study

BACKGROUND

The incidence of periprosthetic femoral fractures is increasing because of an increasing number of primary THAs and TKAs. High rates of complications and mortality are associated with periprosthetic fractures, but few studies have evaluated and compared the population-based incidences of these events after fractures.

QUESTIONS/PURPOSES

(1) What is the annual incidence of periprosthetic fractures treated with surgery in one hospital district in Finland? (2) How are those incidences changing over time? (3) What is the risk of complications, reoperations, and death after those injuries?

METHODS

This register-based study evaluated 2259 patients who underwent revision THA or TKA or any surgery for a femoral fracture between January 2004 and December 2016 at the only hospital in our district where these types of operations are performed. During the study period, the diagnosis and operation codes of the operated-on patients varied greatly, and they were somewhat inaccurate. We thus evaluated radiographs of all 2259 patients one by one, and created inclusion and exclusion criteria based on radiologic findings and medical records. Of those, 12% (279 of 2259) had periprosthetic fractures that met the inclusion criteria, and from these, we formed two study groups (periprosthetic proximal femur fractures, n = 171; periprosthetic distal femur fractures, n = 108). Eighty-eight percent (1980 of 2259) of the patients were excluded because they were treated for a condition other than periprosthetic femoral fracture. The follow-up period ended in December 2019 or at the time the patient died. To evaluate the population-based incidence, we drew the number of individuals with THA or TKA in the hospital district from the Finnish Arthroplasty Register and the Finnish Hospital Discharge Register. The characteristics of patients with operatively treated periprosthetic femoral fractures were evaluated in terms of age, gender, fracture type, implant type, and time from the index operation to periprosthetic fracture. The annual incidences of periprosthetic femoral fractures are summarized per 1000 person-years of individuals living with an implanted THA or TKA and per 100,000 individuals per year living in our hospital district. The risks of death, complications, and reoperations were evaluated for both groups, and comparisons were made in terms of patient characteristics.

RESULTS

The mean annual incidence of operatively treated periprosthetic proximal femur fractures per 1000 people living with THA implants was 2.3 ± 0.9 (95% confidence interval 1.8 to 2.7) per year, and for those with periprosthetic distal femur fractures with TKA implants, it was 1.3 ± 0.6 (95% CI 1.0 to 1.7). There was an increasing trend in the incidence of periprosthetic proximal femur fractures from 1.6 to 3.8 (95% CI 1.8 to 2.8) per 1000 arthroplasties, and it increased from 0.4 to 1.7 (95% CI 2.4 to 4.4) for periprosthetic distal femur fractures between 2004 and 2016. The mean population-based incidence of periprosthetic proximal femur fractures per 100,000 person-years was 5.3 ± 2.2 (95% CI 4.1 to 6.4) per year, and for periprosthetic distal femur fractures, it was 3.4 ± 1.7 (95% CI 2.5 to 4.4). The incidence of periprosthetic proximal femur fractures related to 100,000 person-years increased from 3.2 to 8.9 (95% CI 3.9 to 6.6), while the incidence of periprosthetic distal femur fractures increased from 1.3 to 4.4 (95% CI 2.4 to 4.8) during the study period. The cumulative incidence of major complications after periprosthetic proximal femur fracture was 8.8% at 1 year (95% CI 5.1% to 13.6%) and 12.3% at 10 years (95% CI 7.5% to 18.4%), and after periprosthetic distal femur fracture, it was 7.4% at 1 year (95% CI 3.5% to 13.4%) and 9.3% at 10 years (95% CI 4.7% to 15.7%). The cumulative incidence of reoperation after periprosthetic proximal femur fracture was 10.5% at 1 year (95% CI 6.5% to 15.7%) and 13.5% at 10 years (95% CI 8.9% to 19.1%), and for periprosthetic distal femur fracture, it was 8.3% at 1 year (95% CI 4.1% to 14.5%) and 13.8% at 10% years (95% CI 7.8% to 21.4%). The cumulative incidence of death after periprosthetic proximal femur fracture was 8.2% at 1 year (95% CI 4.7% to 12.9%) and 47.3% at 10 years (95% CI 38.1% to 55.9%), and after periprosthetic distal femur fractures, it was 14.8% at 1 year (95% CI 8.8% to 22.2%) and 67.8% at 10 years (95% CI 56.3% to 76.9%).

CONCLUSION

The increased use of THA and TKA has led to an increase in the incidence of operatively treated periprosthetic fractures, which means there will be more revisions in the future. Older age, frailty of these patients, and often-complicated fracture patterns are related to a high rate of complications, reoperations, and mortality. Healthcare systems must prepare for a large increase in revisions for periprosthetic fracture, which are morbid events for patients and costly ones for healthcare systems.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Postoperative Load Bearing in Periprosthetic Femoral Fractures Around Hip Arthroplasty: A Survey Among Orthopedic Surgeons in the Netherlands

INTRODUCTION

Permissive weight bearing (PWB) has relatively recently been implemented to optimize rapid clinical recovery and restoration of function in patients suffering lower extremity fractures. PWB shows outcome advantages in this patient category. Currently, there are no decisive recommendations on postoperative load-bearing management after surgically treated periprosthetic femoral fractures (PPFF) around hip arthroplasty. The objective is to investigate the current postoperative practice of weight-bearing instructions for patients with surgically treated PPFF, accounting for differences in types of periprosthetic fractures and treatment options among Dutch orthopedic surgeons.

MATERIALS AND METHODS

An online survey was distributed among the members of the hip and trauma working groups of the Dutch Orthopedic Association.

RESULTS

The response rate was 13% (n=75). The main finding was that postoperative load bearing regimes in Vancouver A, B, and C PPFFs differed greatly among Dutch orthopedic surgeons, and there was no decisive guideline or consensus in postoperative load bearing regimes after surgically treated PPFF was used in the Netherlands.

CONCLUSION

In the absence of decisive guidelines or consensus, more research is needed to explore the efficacy of PWB after surgically treated PPFF.

Revision Total Hip Arthroplasty with a Modular Fluted Tapered Stem for a Periprosthetic Femoral Fracture

Background

As the number of primary total hip arthroplasty procedures performed each year continues to rise, so too do the number of complications, including periprosthetic femoral fracture1-9. Vancouver B2 and B3 periprosthetic femoral fractures are difficult to treat because they require the surgeon to simultaneously manage a femoral fracture and gain new implant fixation. Fluted tapered stems have advanced the treatment of periprosthetic femoral fractures by providing immediate axial and rotational implant fixation distal to the fracture10-18. Modular fluted tapered stems provide the added practical advantage of allowing length and anteversion adjustment after implantation of the distal fixation portion of the stem.

Description

In this technique, a modified extended trochanteric osteotomy incorporating the fracture is utilized to gain access to the loose femoral implant and femoral diaphyseal canal. The femoral diaphyseal canal is then sequentially reamed in 1-mm increments. A fluted tapered stem with the appropriate length, diameter, and axial and rotational stability is inserted into the canal. A proximal body is then chosen that establishes the appropriate leg length, femoral offset, and version. The final proximal body is engaged into the fluted tapered stem. Finally, the fracture is fixed around the implant with a combination of cables or wires.

Alternatives

Historically, implants such as extensively porous coated stems were utilized to treat Vancouver B2 or B3 periprosthetic femoral fractures. Unfortunately, these implants were associated with high rates of failure and revision7,9.

Rationale

The introduction of a fluted tapered stem provided a more reliable implant that achieves immediate axial and rotational stability. In addition, utilizing a fluted tapered stem allowed for a more soft-tissue-preserving approach to these complex injuries, in turn allowing the fracture to be reduced around the implant proximally with cerclage cables and or wires. Modular fluted tapered stems provide the additional advantage of allowing the surgeon to modify leg length, offset, and femoral version, independently of the fluted tapered stem. As a result of these unique advantages, these stems were introduced several years ago for the treatment of Vancouver B2 or B3 periprosthetic femoral fractures.

Expected Outcomes

Contemporary series have demonstrated that the use of a modular fluted tapered stem leads to improved implant survivorship and clinical outcomes with lower complication rates for Vancouver B2 and B3 periprosthetic femoral fractures1,10-12,14-19.

Important Tips

Template both the fluted tapered stem and proximal body preoperatively. The proximal body should be templated at the ideal hip center of rotation that appropriately restores leg lengths and offset. Template the fluted tapered stem so that it provides appropriate isthmic fit and bypasses the most distal extent of the fracture by at least 2 cortical diameters.Utilize a modified extended trochanteric osteotomy for your exposure in order to facilitate visualization of the fracture and to provide direct access to the femoral canal.Place a prophylactic cable prior to preparing the femur for the implant in order to help prevent iatrogenic fracture.Place a trial stem and obtain intraoperative anteroposterior and lateral radiographs in order to assess the position of the implants and the risk of anterior cortical perforation.When placing the final implants, be sure the fluted tapered stem has both axial and rotational stability.Reduce and fix the fracture after the final implants are placed and the hip is reduced.

Acronyms and Abbreviations

AP = anteroposteriorMFT = modular fluted tapered (stem)ETO = extended trochanteric osteotomyTHA = total hip arthroplastyCT = computed tomographyPJI = periprosthetic joint infection.

Treatment of Vancouver B2 Femur Fractures With Open Reduction Internal Fixation Versus Revision Arthroplasty

Background Vancouver B2 periprosthetic femur fractures have traditionally been treated with revision arthroplasty. However, there is increasing evidence that open reduction and internal fixation (ORIF) may be a valid alternative treatment strategy. The purpose of this study was to compare the outcomes of ORIF versus revision arthroplasty for the treatment of Vancouver B2 fractures and evaluate the influence of the treating surgeon's fellowship training on treatment selection. Methodology This was a retrospective cohort study of 31 patients treated for Vancouver B2 periprosthetic fractures (16 ORIF and 15 revision arthroplasty) at a single academic Level 1 trauma center. Outcome measures included one-year mortality, revision, reoperation, infection, and blood loss. Results There were no statistically significant differences in revision, reoperation, or infection at an average follow-up of 65 weeks. Median estimated blood loss was higher in the arthroplasty group (700 cc versus 400 cc; P = 0.04). There were five deaths in the ORIF group versus one in the revision group (P = 0.18). Cases treated by surgeons with fellowship training in arthroplasty were more likely to be treated with revision arthroplasty (10/11, 90.9%) than those treated by surgeons with fellowship training in trauma (5/15, 33.3%; P < 0.01). Conclusions There was no difference in outcomes between the two treatment strategies, but revision was associated with higher blood loss. The appropriate treatment method should be based on surgeon familiarity and patients' characteristics.

Utility of synovial calprotectin lateral flow test to exclude chronic prosthetic joint infection in periprosthetic fractures: a prospective cohort study

The diagnosis of periprosthetic joint infection (PJI) requires a combination of various clinical, laboratory, microbiological and histopathological parameters. A concomitant periprosthetic fracture (PPF) further complicates the diagnosis as it causes a confounding local inflammatory response. Synovial calprotectin has been demonstrated as a promising biomarker of PJI. The purpose of the present study was to evaluate the reliability of synovial calprotectin for the pre- or intraoperative diagnosis of PJI in PFF. 30 patients with PPF and implant loosening were included in this prospective study. Synovial fluid with white blood cells and percentage of polymorphonuclear neutrophils, serum C-reactive protein, and synovial calprotectin using a lateral-flow assay were tested against the EBJIS definition with adjusted thresholds to account for the local inflammation. 14 patients were postoperatively classified as confirmed infections (ten total hip arthroplasties and fourtotal knee arthroplasties). The calprotectin assay yielded a sensitivity of 0.71 [0.48; 0.95], a specificity of 0.69 [0.46; 0.91], a positive predictive value of 0.67 [0.43; 0.91] and a negative predictive value of 0.73 [0.51; 0.96]. Calprotectin is a promising diagnostic parameter for the detection of a PJI in a PPF. The lateral flow assay offers prompt results, which may further assist the surgeon in addition to already existing parameters of PJI diagnostics to diagnose concomitant PJI in PPF during surgery.

Modular Fluted Tapered Stems for Periprosthetic Femoral Fractures: Excellent Results in 171 Cases

BACKGROUND

Modular fluted tapered (MFT) stems have advanced treatment of Vancouver B2 and B3 periprosthetic femoral fractures, but series to date have been limited with respect to cohort size and follow-up duration. The purpose of this study was to determine implant survivorship, radiographic results, complications, and clinical outcomes of Vancouver B2 and B3 periprosthetic femoral fractures treated with MFT stems in a large series of patients.

METHODS

We identified 171 Vancouver B2 (109) and B3 (62) periprosthetic femoral fractures treated with an MFT stem between 2000 and 2018 using our institutional total joint registry. The mean age was 75 years, 50% were female, and the mean body mass index was 29 kg/m2. The median stem diameter was 18 mm and median stem length was 210 mm. The cumulative incidences of revision and reoperation with death as the competing risk were calculated, radiographs were reviewed, and clinical outcomes were evaluated using the Harris hip score (HHS). The mean follow-up was 5 years.

RESULTS

The 10-year cumulative incidence of any revision was 10%. There were 17 revisions, of which only 3 were for the distal fluted portion of the MFT stem. Revision indications included periprosthetic joint infection (PJI) (n = 6) and dislocation (n = 11). The 10-year cumulative incidence of any reoperation was 15%. In addition to the above 17 revisions, there were 7 reoperations for superficial wound complications (n = 4), Vancouver B1 periprosthetic femoral fracture (n = 1), vascular occlusion (n = 1), and acetabular cartilage degeneration requiring an acetabular component (n = 1). Radiographically, there was 1 fracture nonunion. All unrevised MFT stems were radiographically well fixed. Subsidence of ≥5 mm occurred in 11%, but all implants were stable at the most recent follow-up. The mean HHS was 75 at 2 years (n = 71).

CONCLUSIONS

In this large series of 171 Vancouver B2 and B3 periprosthetic femoral fractures treated with MFT stems, we found that such constructs were associated with a high rate of fracture healing and provided extremely reliable and durable implant fixation, with no revisions for aseptic loosening. Dislocation and PJI were the most common complications.

LEVEL OF EVIDENCE

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

The Economic Impact of Lower Extremity Periprosthetic Fractures in a Large Hospital System

BACKGROUND

Periprosthetic fractures (PPFs) place a burden on hospital systems. They occur in older patients with medical comorbidities, as unplanned events requiring technically complex surgeries with expensive implants. The purpose of this study was to describe this patient population and evaluate the economic impact of PPFs on a hospital system.

METHODS

We conducted a retrospective study of PPFs of the hip and knee between 2018 and 2019. Demographics, length of stay (LOS), and discharge disposition were collected. We performed chart and radiographic reviews to determine the fracture classification and type of treatment performed. An analysis of direct inpatient costs was performed and categorized by a fracture type.

RESULTS

We identified 213 periprosthetic hip and 151 periprosthetic knee fractures. The mean age of hip patients was 77 years, and 71% were female. The average surgery time was 194 minutes, LOS was 5.01 days, and 71% were discharged to a skilled nursing facility (SNF). The mean age of knee patients was 76 years, and 79% were female. The average surgery time was 174 minutes, LOS was 5.12 days, and 70% were discharged to a SNF. The median direct cost of hip fractures was $17,108, with Vancouver B2 and B3 costing significantly more at $19,987 and $23,935, respectively (P value <.0001). The median direct cost of knee fractures was $13,713. Type 3 distal femur fractures cost significantly more at $37,445 (P value <.0001).

CONCLUSION

PPFs create a significant economic impact on hospital systems. We stratified the costs of treatment based on the fracture type. Significantly higher costs are associated with injuries requiring revision implants.

Modular or Monolithic Tapered Fluted Prostheses for Periprosthetic Fractures: Which One Could Work for You?

Periprosthetic fracture around a femoral component is a potentially devastating complication after total hip arthroplasty. Surgical treatment is often technically demanding and requires a thorough understanding of fracture care and revision joint reconstruction. Advancements in femoral component designs for revision total hip arthroplasty have improved management of this challenging complication. It is important for surgeons to understand which femoral component design might best suit their needs. We present an overview of revision total hip arthroplasty in the setting of periprosthetic fracture, focusing on comparing the 2 most popular femoral component revision models, the modular and monolithic tapered fluted conical prostheses.

Pathological analysis of periprosthetic soft tissue and modes of failure in revision total joint arthroplasty patients

Objectives

Implant failure leading to revision total joint arthroplasty can occur through a variety of different mechanisms which are typically associated with a soft tissue response adjacent to the implant that provide insight into the underlying etiology of implant failure. The objective of this study was to elucidate mechanisms of implant failure as they relate to histological classification and findings of adjacent periprosthetic tissue.

Methods

Histological analysis of soft tissue adjacent to the implant was performed in 99 patients with an average age of 64 years old and grouped into four categories based on the study conducted by Morawietz et al.:Type I (N = 47)Wear particle induced typeType II (N = 7)Infectious typeType III (N = 19)Combined type I and IIType IV (N = 26)Indeterminant typeModes of failure were categorized into five groupings based on the study conducted by Callies et al.: Instability (N = 35), Aseptic Loosening (N = 24), Hardware and/or Mechanical Failure (N = 15), Septic (N = 13), and Other failures (N = 12). We calculated odds ratios and conducted regression analysis to assess the relationship between modes of failure and histological findings as well as modes of failure and comorbidities.

Results

Hardware/mechanical failure was independently correlated with histological findings of anucleate protein debris, histiocytes, Staphylococcus epidermidis, and synovitis. Furthermore, hardware/mechanical failure was independently correlated with osteosarcoma as a co-morbidity. Septic failure was associated with histological findings of Enterococcus, granulation tissue, and tissue necrosis as well as comorbidities of Crohn's disease, deep venous thrombosis, lung disease, and rheumatoid arthritis. Infection was 5.8 times more likely to be associated with Type II histology. Aseptic loosening was associated with histologic findings of synovitis.

Conclusion

Our findings support the existing literature on periprosthetic tissue analysis in revision total joint arthroplasty which may improve surgeon understanding of the patholophysiological mechanisms that contribute to implant failure and revision surgery.

Retrospective Population-Based Cohort Study of Incidence, Complications, and Survival of 202 Operatively Treated Periprosthetic Femoral Fractures

BACKGROUND

The aim of this study is to investigate the population and primary total hip arthroplasty (THA)-based incidences, fracture types, complications, and survival of operatively treated periprosthetic femoral fracture (PFF).

METHODS

This retrospective study reviewed 202 cases of operatively treated PFFs in a study period from January 2004 to December 2016. The Vancouver classification was used to classify PFFs.

RESULTS

The incidence of PFF related to 1000 primary THAs per year was 2.7 (standard deviation 1.0, range 0.9-4.5) at a defined hospital district area during the study period. The mean population-based incidence of operatively treated PFFs raised from 1.6 to 4.5 per 100,000 person-years during the study period. The B1-type fracture was the most common fracture type in 71 of 202 (35%) of these PFFs. The cumulative incidence of re-revision was 10.9% at 1 year and 15.6% at 15 years (95% confidence interval [CI] 10.9-21.0). The cumulative incidence for other major complications was 6.4% at 1 year and 9.9% at 15 years (95% CI 5.9-15.0). The cumulative incidence of death after PFF was 7.4% at 1 year and 56.3% at 15 years (95% CI 41.3-68.8) during the follow-up time from January 1, 2004 to December 31, 2019.

CONCLUSION

This country-specific study showed a 3-fold increasing trend in the incidence of operatively treated PFFs from 2004 to 2016 per 1000 THAs. The Vancouver type B1 fracture was the most common type. A high number of complications were associated with PFFs and 7.4% of the patients had died within 1 year after PFF surgery.

What Are the Contemporary Etiologies for Revision Surgery and Revision After Primary, Noncemented Total Hip Arthroplasty?

INTRODUCTION

Contemporary failure etiologies of primary total hip arthroplasties (THAs) have not been precisely defined because of heterogeneity of referral practices.

METHODS

A single-institution registry of 4,555 primary, noncemented THAs performed by subspecialty trained arthroplasty surgeons between 2000 and 2012 was analyzed. Only revision surgeries and revisions that occurred after THAs initially performed at the institution were included.

RESULTS

The estimated 10-year survivorships free from THA revision surgery, modular implant revision, and nonmodular implant revision were 98.2%, 98.1%, and 96.3%, respectively. The most common reasons for revision surgeries were wound-related complications (49%), periprosthetic fracture (25%), and pain (18%). Hip instability (53%) and acute periprosthetic joint infection (26%) were the most common etiologies of revision procedures with isolated exchange of at least one modular implant. The most common reasons for replacement or removal of nonmodular implant were periprosthetic fracture (32%), aseptic loosening (22%), and adverse tissue reaction (17%).

DISCUSSION

Focusing on primary THAs initially performed by a contemporary, subspecialty practice allowed an accurate determination of etiologies and rates of failure (defined by revision surgery or revision) after THA.

LEVEL OF EVIDENCE

Level IV.

Do Mortality and Complication Rates Differ Between Periprosthetic and Native Hip Fractures?

BACKGROUND

Epidemiological estimates indicate a rising incidence of periprosthetic hip fractures. While native hip fractures are known to be a highly morbid condition, a significant body of research has led to improved outcomes and decreased complications following these injuries. Comparatively, little research has evaluated the relative morbidity and mortality of periprosthetic hip fractures. The purpose of this study was to compare the morbidity and mortality of periprosthetic vs native hip fractures.

METHODS

Using the National Surgical Quality Improvement Program (NSQIP) database, 523 periprosthetic hip fractures were matched to native hip fractures using propensity scores. The 30-day rates of complications were compared using McNemar's test. A multivariate regression was then used to determine independent risk factors for mortality following periprosthetic fracture.

RESULTS

Mortality was similar between groups (periprosthetic: 2.7% vs native: 3.4%; P = .49). Periprosthetic fractures exhibited a greater rate of overall (63.1% vs 38.6%; P < .001) and minor complications (59.1% vs 34.4%; P < .001). There was an increased rate of return to the operating room (7.8% vs 3.1%; P < .001) and blood transfusion in the periprosthetic group (54.9% vs 30.2%; P = .001). Age greater than 85 (odds ratio 9.21) and dependent functional status (odds ratio 5.38) were both independent risk factors for mortality following periprosthetic fracture.

CONCLUSIONS

While native hip fractures are known to be highly morbid, our findings suggest that periprosthetic hip fractures have a similar mortality with significantly higher short-term morbidity. Future research is warranted to better understand risk factors and prevention strategies for complications in this subset of patients.

Perioperative Periprosthetic Fractures Associated With Primary Total Hip Arthroplasty

BACKGROUND

Periprosthetic fracture (PPF) is a rare but devastating complication of primary total hip arthroplasty (THA). While PPF is associated with increased morbidity and mortality, early revision rate, and poor patient outcome, there is a paucity of data on patient and hospital-dependent risk factors. Using a large administrative database, we investigated epidemiology and the risk factors associated with perioperative PPF after primary THA.

METHODS

We performed a retrospective review of the National Inpatient Sample records from 2006 to 2011 and identified 1062 PPFs of 1,187,969 patients using International Classification of Diseases, Ninth Revision code for PPF (996.44). We then analyzed sociodemographic characteristics, comorbidities, and hospital characteristics of our study population.

RESULTS

The overall incidence of PPF in National Inpatient Sample database was 0.089% (8.9 per 10,000 THAs). Patient-dependent risk factors were: female (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.67-2.22), low household income (OR 1.4, 95% CI 1.18-1.65), Medicaid (OR 1.89, 95% CI 1.39-2.57), and uninsured (OR 2.74, 95% CI 1.63-4.61). Patients with malnutrition and hemiparesis/hemiplegia were associated 10-fold and 6-fold risk of PPF. Nonteaching hospitals (OR 1.15, 95% CI 1.01-1.32), hospitals in northeast (OR 1.29, 95% CI 1.04-1.59), and rural hospitals (OR 1.27, 95% CI 1.06-1.53) had higher incidence of PPF.

CONCLUSION

Our study demonstrates that the incidence of PPF was low in our study population, and greater awareness is needed when performing primary THAs in patients with risk factors identified in our study to prevent PPF.

Mortality Following Surgical Management of Vancouver B Periprosthetic Fractures

OBJECTIVES

The goals of this study are to evaluate mortality after Vancouver B periprosthetic fractures and determine predictors of mortality; compare mortality among patients with loose femoral stems treated with revision arthroplasty versus fixation alone; compare mortality among patients with radiographically "indeterminate" fractures treated with revision or fixation; and evaluate the rate of return to surgery for patients who underwent revision compared with fixation.

DESIGN

Retrospective study.

SETTING

Three academic level 1 trauma centers.

PATIENTS/PARTICIPANTS

Two hundred three patients treated for Vancouver B periprosthetic fractures.

INTERVENTION

N/A.

MAIN OUTCOME MEASUREMENTS

The primary outcome measure was mortality. The secondary outcome measure was reoperation because of infection, failure of fixation, dislocation, or other mechanical failure.

RESULTS

Overall 1-year survival was 87% and 5-year survival was 54%. Among patients with loose femoral stems, there was no significant difference with regard to survival between patients treated with fracture fixation or revision arthroplasty (1-year survival 83% vs. 85%, 5-year survival 41% vs. 58%). Among patients whose radiographs were classified as indeterminate, there was no significant difference between patients treated with fracture fixation alone or revision arthroplasty. There was no significant difference between total reoperation rates between the two groups (11% vs. 16%).

CONCLUSION

This study suggests that there is no discernible survival benefit to treating patients with periprosthetic fractures with either revision arthroplasty or fixation alone. Therefore, from a mortality perspective, when faced with Vancouver B periprosthetic fractures, the orthopaedic surgeon should feel comfortable performing the type of intervention he/she is most proficient to perform.

LEVEL OF EVIDENCE

Prognostic level III. See Instructions for Authors for a complete description of levels of evidence.

Frequency and Treatment Trends for Periprosthetic Fractures About Total Hip Arthroplasty in the United States

BACKGROUND

Periprosthetic hip fractures (PPHFx) are challenging complications that have become increasingly more prevalent. Wide variability exists in the quality and size of prior studies pertaining to hospital stay information. This study used the largest publicly available database in the United States to evaluate perioperative hospital data of PPHFx.

METHODS

The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample was used to analyze trends related to the frequency, fracture type, mortality, treatment, patient demographics, time to surgery, length of stay (LOS), and hospital charges associated with PPHFx from 2006-2010.

RESULTS

From 2006-2010, average patient age (76.7 years), hospital characteristics, rate of PPHFx, treatment choice, LOS (8.03 days), mortality (2.6%), disposition (78.1% to skilled nursing facility or inpatient rehab), and time to procedure (1.98 days) all remained relatively stable. The southern United States had the highest frequency of PPHFx and females had nearly twice the rate of PPHFx each year at an average of 67%. Despite these consistencies, hospital charges increased by an average of 8.3% per year over the study period ($27,683 over 5 years, P < .0001).

CONCLUSION

In the era of containing cost while improving quality of care, this study demonstrates that despite consistent treatment trends of PPHFx, hospital charges are increasing independently. Regardless, surgeons can work to reduce LOS and charge to post acute care facilities to lessen spending. Refining our understanding of these relationships will be fundamental to further improving quality of care and cutting cost associated with these fractures.

Diagnosing Infection in the Setting of Periprosthetic Fractures

BACKGROUND

The diagnosis of periprosthetic joint infection is particularly challenging in patients with periprosthetic fractures. The purpose of this study was to investigate the utility of commonly used diagnostic tests for periprosthetic joint infection in patients with a periprosthetic fracture.

METHODS

Of 121 patients treated with a periprosthetic fracture (97 hips, 24 knees, mean age: 72.9), 14 (11.6%) met Musculoskeletal Infection Society criteria for infection. Diagnostic variables were evaluated using logistic regression models for the prediction of infection and receiver operating characteristics curves.

RESULTS

The synovial white blood cell (WBC) count and differential were the best diagnostic tests, with good test performance (area under the curve, 84%) and optimal cutoffs of 2707 WBC/uL and 77% polymorphonuclear cells. The erythrocyte sedimentation rate and C-reactive protein were found to have overall lower test performance but remained relatively sensitive at standard cutoff values of 30 mm/h and 10 mg/L, respectively.

CONCLUSION

The synovial fluid WBC count and differential are the best tests with optimal cutoff values that are similar to those used for patients without a periprosthetic fracture.

Clinical characteristics and risk factors of periprosthetic femoral fractures associated with hip arthroplasty: A retrospective study

Periprosthetic femoral fracture (PFF) is a complicated complication of both primary and revision hip arthroplasty with an increasing incidence. The present study aimed to summarize the clinical characteristics and identify the risk factors for PFF which would be potentially helpful in the prevention and treatment of PFF.We retrospectively analyzed the clinical data of 89 cases of PFF, and a case-control study was designed to identify the potential risk for intraoperative and postoperative PFF in both primary and revision hip arthroplasty.The overall incidence of PFF was 2.08% (intraoperative: 1.77%, postoperative: 0.30%, revision: 13.60%, and primary: 0.97%). The most commonly used treatment strategy was fixation with cerclage wire or band for intraoperative PFF, whereas long stem revision with plate or cortical allograft strut fixation was the main treatment strategy for postoperative PFF. The risk factors for intraoperative PFF in primary total hip arthroplasty (THA) included the diagnosis of development dysplasia of the hip (DDH) (odds ratio [OR] = 5.01, 95%CI, 1.218-20.563, P=0.03) and CBR ≥ 0.49 (OR = 3.34, 95%CI, 1.138-9.784, P = 0.03). The increased age was associated with increased incidence of postoperative PFF in primary THA (OR = 1.09, 95%CI, 1.001-1.194, P = 0.04). As for the intraoperative PFF in revision THA, we found that receiving multiple operations before revision (OR = 2.45, 95%CI, 1.06-5.66, P = 0.04), revisions due to prosthetic joint infection (OR = 6.72, 95%CI, 1.007-44.832, P = 0.04), the presence of cementless implant before revision (OR = 13.54, 95%CI, 3.103-59.08, P = 0.001), and femoral deformity (OR = 8.03, 95%CI, 1.656-38.966, P = 0.01) were all risk factors.Screening for high-risk patients, preoperative templating, and detailed discharge instructions may be the potential strategies to reduce the incidence of PFF. The treatment of PFFs should take into account Vancouver classification system, patient's characteristics as well as the experience of the operating surgeon.

Bilateral atypical femoral fracture and end-stage arthritis of the hip, treated with total hip arthroplasty

The prolonged use of bisphosphonates has been associated with an increased rate of atypical femoral fracture. A 77-year-old woman with prolonged bisphosphonate use presented to our office with groin pain and end-stage arthritis, She was scheduled for a total hip replacement. Before the surgery and with minimal trauma, the patient then suffered a displaced atypical femoral fracture. She underwent a total hip replacement as a treatment for her fracture and her arthritis. Subsequently, the patient presented with pain in the contralateral thigh with an incomplete atypical femoral fracture. That side was also treated with a total hip arthroplasty. An uncemented stem with open reduction internal fixation and a long cemented stem were used on the complete fracture and incomplete fracture sides, respectively. At a follow-up of 2 years, the patient had no pain and had excellent function demonstrating the short-term success of both cemented and uncemented stems in total hip arthroplasty after atypical femoral fractures.

Incidence and predisposing factors of periprosthetic proximal femoral fractures: a literature review

PURPOSE

The purpose of this review article was to investigate the incidence and predisposing factors for periprosthetic proximal femoral fractures (PFF) following total hip arthroplasty.

METHODS

We performed a comprehensive search of the medical literature in MEDLINE and EMBASE databases to review articles related to PFF, their incidence and risk factors.

RESULTS AND CONCLUSIONS

The incidence of PPF after primary THA was, in general, lower than after revision THA both for intra- and postoperative PFF. The rate of intraoperative PFF ranged from 0.1% to 27.8% and of postoperative PFF from 0.07% to 18%. Predisposing factors for intraoperative PFF are osteoporosis, rheumatoid arthritis, femoral preparation and surgical technique used to insert the rasp or femoral component, the use of press-fit cementless stems, and revision THA. In case of postoperative PFF, the following seem to be significant risk factors: advanced age, female gender, post-traumatic osteoarthritis, osteoporosis and rheumatoid arthritis, proximal femoral deformities, previous surgery of the affected hip, implant type (especially cementless stems and press-fit implantation), technical errors such as cortical perforation, cortical stress risers, low-energy trauma, osteolysis, loosening and revision THA.

Higher reliability and validity of Baba classification with computerised tomography imaging and implant information for periprosthetic femoral fractures

PURPOSE

Baba classification for periprosthetic femoral fracture focuses on the positional relationship between the implant design and fracture site. The objective of this study was to investigate whether the addition of CT images and implant information to plain radiograms increases the reliability of Baba classification to a level higher than that of Vancouver classification.

METHODS

Twenty patients were randomly selected from 61 patients with periprosthetic femoral fracture between 2009 and 2014. After Vancouver and Baba classifications were fully explained to six orthopedic surgeons (three experts and three non-experts), plain radiograms, CT imaging and implant information at the time of injury were presented, and the inter- and intra-observer reliability based on the Vancouver and Baba classifications and accuracy rates of stem stability were investigated.

RESULTS

When interobserver reliability was made based on only radiograms, the mean κ value of Baba classification-based judgments made by the experts was 0.76, and those of Vancouver classification-based judgments made by the experts was 0.41. When interobserver reliability was made based on the radiograms and CT images and implant information, the mean κ value of Baba classification-based judgments made by the experts was 0.94, and those of Vancouver classification-based judgments were 0.48. Intra-observer reliability of Baba classification was 0.81 in the experts. Validity analysis showed 95.0% agreement within all subgroups.

CONCLUSIONS

Reliability and validity of Baba classification was improved when additional information was given. We believe that this new classification is useful to establish a therapeutic strategy for femoral fractures around the stem.