Ten-year comparison of two different techniques for femoral bone cavity preparation-broaching versus compaction in patients with cementless total hip arthroplasty : a randomized radiostereometric study of 30 total hip arthroplasties in 15 patients operated bilaterally

Aims

Femoral bone preparation using compaction technique has been shown to preserve bone and improve implant fixation in animal models. No long-term clinical outcomes are available. There are no significant long-term differences between compaction and broaching techniques for primary total hip arthroplasty (THA) in terms of migration, clinical, and radiological outcomes.

Methods

A total of 28 patients received one-stage bilateral primary THA with cementless femoral stems (56 hips). They were randomized to compaction on one femur and broaching on the contralateral femur. Overall, 13 patients were lost to the ten-year follow-up leaving 30 hips to be evaluated in terms of stem migration (using radiostereometry), radiological changes, Harris Hip Score, Oxford Hip Score, and complications.

Results

Over a mean follow-up period of 10.6 years, the mean stem subsidence was similar between groups, with a mean of -1.20 mm (95% confidence interval (CI) -2.28 to -0.12) in the broaching group and a mean of -0.73 mm (95% CI -1.65 to 0.20) in the compaction group (p = 0.07). The long-term migration patterns of all stems were similar. The clinical and radiological outcomes were similar between groups. There were two intraoperative fractures in the compaction group that were fixed with cable wire and healed without complications. No stems were revised.

Conclusion

Similar stem subsidence and radiological and clinical outcomes were identified after the use of compaction and broaching techniques of the femur at long-term follow-up. Only the compaction group had intraoperative periprosthetic femur fractures, but there were no long-term consequences of these.

Cite this article: Bone Jt Open 2021;2(12):1035–1042.

Perioperative Considerations in Osteogenesis Imperfecta: A 20-Year Experience with the Use of Blood Pressure Cuffs, Arterial Lines, and Tourniquets

Osteogenesis imperfecta (OI) is a rare genetic connective-tissue disorder with bone fragility. To avoid iatrogenic fractures, healthcare providers have traditionally avoided using non-invasive blood pressure (NIBP) cuffs and extremity tourniquets in the OI population in the perioperative setting. Here, we hypothesize that these procedures do not lead to iatrogenic fractures or other complications in patients with OI. A retrospective study of all children with OI who underwent surgery at a single tertiary care children’s hospital from 1998 to 2018 was performed. Patient positioning and the use of NIBP cuffs, arterial lines, and extremity tourniquets were documented. Fractures and other complications were recorded. Forty-nine patients with a median age of 7.9 years (range: 0.2–17.7) were identified. These patients underwent 273 procedures, of which 229 were orthopaedic operations. A total of 246 (90.1%) procedures included the use of an NIBP cuff, 61 (22.3%) an extremity tourniquet, and 40 (14.7%) an arterial line. Pediatric patients with OI did not experience any iatrogenic fractures related to hemodynamic monitoring or extremity tourniquet use during the 20-year period of this study. Given the benefits of continuous intra-operative hemodynamic monitoring and extremity tourniquets, we recommend that NIBP cuffs, arterial lines, and tourniquets be selectively considered for use in children with OI.

Perioperative Fractures in Cementless Total Hip Arthroplasty Using the Direct Anterior Minimally Invasive Approach: Reduced Risk With Short Stems

BACKGROUND

The direct minimally invasive anterior approach (DMIAA) and the use of uncemented stems demonstrated an increase in intraoperative fractures in recent literature. Whether the different design of the stems additionally influences the incidence of perioperative local complications, was the goal of this study.

METHODS

From January 2008 until June 2010, all patients undergoing primary cementless total hip arthroplasty, using a DMIAA, were consecutively included. The choice of the implant was defined by the day of operation. Age, gender, body mass index, type of prosthesis, and the practical experience of the performing surgeon were retrospectively analyzed. Of main interest were intraoperative fractures, postoperative hematoma, and wound healing.

RESULTS

Six hundred forty consecutive patients (64 years [18-94], 339 female, 53%, body mass index 26) have been included. A Quadra-H stem (Medacta) was used in 457 patients (71%). In 183 (29%) patients, a short stem designed for the DMIAA (130 Fitmore, Zimmer and 53 AMIStem, Medacta) was used. We counted 34 (5.3%) intraoperative fractures (16 at the greater trochanter, 18 proximal shaft fractures), 20 (4%) hematomas, and 8 (2%) wound healing problems. The standard length stem showed more local complications (11.8% vs 4.4%) (P = .014, odds ratio 1.63, confidence interval 1.1-2.4) and significantly more (6.8% vs 1.6%) intraoperative fractures (P = .027, odds ratio 1.98, confidence interval 1.1-3.6).

CONCLUSION

The standard length stem showed more perioperative complications, especially periprosthetic fractures. It seems that these implants not only put more stress to proximal osseous structures, but there might also be more traction and irritation to the soft tissue while preparing, resulting in more hematomas and wound healing problems.

Reduced Incidence of Intraoperative Femur Fracture With a Second-Generation Tapered Wedge Stem

BACKGROUND

Intraoperative fractures during total hip arthroplasty (THA) are more common when using cementless stems. The purpose of this study was to investigate the impact of a new shorter second-generation cementless, tapered wedge stem with improved proximal femoral fit in reducing the incidence of intraoperative fracture.

METHODS

A retrospective study was conducted on primary THA cases performed at a single institution using a first-generation or second-generation cementless stem from 2006-2016. All intraoperative femur fractures were identified, as well as early 30-day postoperative periprosthetic femur fractures, which could represent nondisplaced intraoperative fractures that were initially missed. Risk for intraoperative femur fracture was analyzed using logistic regression, accounting for demographic covariates and surgeon.

RESULTS

Of 6473 primary THA performed with a cementless, tapered wedge stem during the study period, 3126 used a first-generation stem and 3347 used a second-generation stem. The incidence of intraoperative fracture was 1.79% for first-generation stems and 0.24% for second-generation stems, representing a 7.5-fold reduction of risk for fracture. After accounting for covariates, the odds of intraoperative fracture were 0.33 using the second-generation stem relative to the first-generation stem (P = .01). However, there was no significant difference in the odds of early 30-day postoperative fractures using the second-generation stem (odds ratio 0.93, P = .56).

CONCLUSION

A new second-generation cementless stem resulted in a 7.5-fold decrease in the incidence of intraoperative femur fracture compared with the preceding stem.