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Although dual implant constructs have recently been explored with promising results in very distal periprosthetic femur fractures (PPKF), the gold standard treatment of Rorabeck and Taylor type III PPKF remains a distal femur replacement or a highly constrained rotating hinge implant. However, this surgery is very aggressive and expensive for functionally low-demanding elderly patients. A new surgical technique using locking plates with polymethyl methacrylate cement augmentation is described to retain the femoral component avoiding its replacement. Four patients were treated and followed up for more than one year postoperative without any complications, their femoral component was retained without any loosening and the mobility in the Barthel Index remained unchanged.
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Periprosthetic acetabular fractures (PPAF) are fractures of the acetabulum with a hip endoprosthesis in place. They are a rare complication, although they are occurring more frequently due to the increase in patients being fitted with total hip arthroplasty (THA) and the long service life of the implants. At present, only a small amount of scientific literature exists, particularly regarding the surgical treatment of these fracture types.The aim of this paper is to provide an overview of the topic of PPAF with a critical review of the current literature and to present the necessary surgical treatment.An evaluation of the current literature on the topic of PPAF with a focus on the surgical treatment of fractures is carried out.Surgical treatment is technically demanding due to the pelvic ring instability with removal of the bone tension for secure acetabular cup fixation and should lead to the recovery of the biomechanical stability of the pelvis and thus the secure anchoring of the acetabular cup. An interdisciplinary approach requiring both trauma surgery and orthopaedic expertise is certainly recommended, as older and comorbid patients with poor bone quality are particularly frequently affected.The treatment of periprosthetic acetabular fractures, especially in older patients, requires not only the individual expertise of surgeon involved in the operation but also a goal-oriented and consistent interdisciplinary approach by the surgeons involved from the fields of orthopaedics and trauma surgery in view of the patients' frequent comorbidities. By working together, the optimal and individualized operation can be performed for the patient.
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BACKGROUND: Most periprosthetic fractures following total hip arthroplasty (THA) are fragility fractures that qualify patients for osteoporosis diagnoses. However, it remains unknown how many patients were diagnosed who had osteoporosis before injury or received the proper evaluation, diagnosis, and treatment after injury. METHODS: We identified 171 Vancouver B2 (109) and B3 (62) periprosthetic femur fractures treated with a modular fluted tapered stem from 2000 to 2018 at 1 institution. The mean patient age was 75 years (range, 35 to 94), 50% were women, and the mean body mass index was 29 (range, 17 to 60). We identified patients who had osteoporosis or osteopenia diagnoses, a fracture risk assessment tool (FRAX), bone mineral density (BMD) testing, an endocrinology consult, and osteoporosis medications. Age-appropriate BMD testing was defined as no later than 1 year after the recommended ages of 65 (women) or 70 years (men). The mean follow-up was 11 years (range, 4 to 21). RESULTS: Falls from standing height caused 94% of fractures and thus, by definition, qualified as osteoporosis-defining events. The prevalence of osteoporosis diagnosis increased from 20% before periprosthetic fracture to 39% after (P < .001). The prevalence of osteopenia diagnosis increased from 13% before the fracture to 24% after (P < .001). The prevalence of either diagnosis increased from 24% before fracture to 44% after (P < .001). No patients had documented FRAX scores before fracture, and only 2% had scores after. The prevalence of BMD testing was 21% before fracture and 22% after (P = .88). By the end of the final follow-up, only 16% had received age-appropriate BMD testing. The proportion of patients who had endocrinology consults increased from 6% before the fracture to 25% after (P < .001). The proportion on bisphosphonate therapy was 19% before fracture and 25% after (P = .08). CONCLUSIONS: Although most periprosthetic fractures following THA are fragility fractures that qualify patients for osteoporosis diagnoses, there remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment. Like nonarthroplasty fragility fractures, a systematic approach is needed after periprosthetic fractures. LEVEL OF EVIDENCE: Level III, retrospective cohort study.
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Artroplastia de Reemplazo de Cadera , Densidad Ósea , Enfermedades Óseas Metabólicas , Osteoporosis , Fracturas Periprotésicas , Humanos , Artroplastia de Reemplazo de Cadera/efectos adversos , Femenino , Anciano , Fracturas Periprotésicas/etiología , Fracturas Periprotésicas/epidemiología , Enfermedades Óseas Metabólicas/etiología , Enfermedades Óseas Metabólicas/epidemiología , Masculino , Anciano de 80 o más Años , Osteoporosis/etiología , Osteoporosis/complicaciones , Persona de Mediana Edad , Adulto , Estudios Retrospectivos , Fracturas del Fémur/etiología , Fracturas del Fémur/cirugía , Medición de Riesgo , Fracturas Osteoporóticas/etiología , Fracturas Osteoporóticas/epidemiología , Prevalencia , Factores de RiesgoRESUMEN
BACKGROUND: There are limited data regarding risk factors associated with periprosthetic medial malleolar fractures in total ankle arthroplasty (TAA). This case-control study aimed to identify the risk factors and analyze the effect of prophylactic screw fixation in preventing a medial malleolar fracture after TAA. METHODS: A case-control study was conducted on 149 patients who underwent primary TAA. Twenty patients with postoperative medial malleolar fractures >4 weeks postoperatively (cases) were identified. An additional 129 patients (controls) were randomly selected from the TAA database. Radiographic evaluation included tibial component coronal alignment and postoperative medial malleolar width. Demographics and radiographic variables were compared between cohorts. Logistic regression was used to investigate the association between medial malleolar fracture and postoperative coronal alignment, medial malleolar width, and prophylactic fixation of the medial malleolus. RESULTS: Mean (SD) medial malleolar width was significantly smaller in the fracture cohort (8.52 mm [1.6]) than in the control group (11.78 mm [1.74]) (P < .001). Mean (SD) tibial component coronal alignment was 92.17 degrees (2.77) in the fracture cohort and 90.21 degrees (1.66) in the control group (P = .002). Regression analysis identified a significant negative association between postoperative medial malleolar width and the probability of fracture (OR = 0.06, 95% CI 0.01, 0.26, P < .001). Varus malalignment of the tibial component was positively associated with the probability of fracture (OR = 1.90, 95% CI 1.27, 2.86, P = .002). Prophylactic screw fixation resulted in more than 90% reduction in the odds of a fracture (OR = 0.04, 95% CI 0.01, 0.45, P = .01). ROC curve analysis determined a medial malleolar width of 10.3 mm as a potential threshold for predicting fracture. CONCLUSION: Decreased medial malleolar width and postoperative varus malalignment were associated with an increased risk of postoperative medial malleolar fracture. Therefore, surgeons should consider prophylactic screw fixation in patients with a medial malleolar width <10.3 mm or at risk of postoperative varus deformity.
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Fracturas de Tobillo , Artroplastia de Reemplazo de Tobillo , Desviación Ósea , Humanos , Estudios de Casos y Controles , Fracturas de Tobillo/cirugía , Fracturas de Tobillo/diagnóstico por imagen , Persona de Mediana Edad , Femenino , Masculino , Desviación Ósea/diagnóstico por imagen , Anciano , Tornillos Óseos , Radiografía , Articulación del Tobillo/cirugía , Articulación del Tobillo/diagnóstico por imagen , Factores de Riesgo , Estudios Retrospectivos , Fijación Interna de Fracturas/métodos , Complicaciones Posoperatorias , Fracturas Periprotésicas/cirugía , Fracturas Periprotésicas/etiologíaRESUMEN
Total hip arthroplasty (THA) is a successful surgery in the treatment of hip pain, but there are potential complications, of which dislocation is one of the most common. Dislocation management is a challenging problem that requires a multimodal approach, and the use of dual mobility implants is an option. We present a patient with a history of femoral neck fracture who underwent THA with a double mobility implant. On the 18 th postoperative day, after a fall to the ground, she developed prosthesis dislocation and had a complication after closed reduction, a subsequent intraprosthetic dislocation. After a radiographic diagnosis, the patient presented mechanical signs of hip flexion caused by a disassociated double mobility implant. The revision surgery was indicated, but the patient chose not to perform the necessary surgical procedure. A careful postoperative study of the radiographs revealed an eccentric femoral head and evidence of disassociated implantation in the surrounding soft tissues. Radiographs after closed reduction of intraprosthetic dislocations should be examined thoroughly.
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BACKGROUND: Periprosthetic humerus fracture is a relatively rare complication following shoulder arthroplasty. As shoulder arthroplasty volume increases, more periprosthetic fractures are anticipated. Some surgeons routinely operate on humerus shaft fractures adjacent to a humeral stem, while others recommend first-line nonoperative treatment. The purpose of this study was to identify and describe the prevalence of operative and nonoperative treatment options for periprosthetic humerus fractures, their associated outcomes, and complications. Our goal was to provide clinical insights for surgeons on the outcomes and complications associated with various treatment options. METHODS: We performed a systematic review of studies reporting clinical or radiographic outcomes and complications after operative or nonoperative treatment of postoperative periprosthetic humerus fractures following shoulder arthroplasty. Subgroup analysis was conducted for differences in surgical outcomes between open reduction internal fixation (ORIF) and revision arthroplasty. RESULTS: Twenty studies met the inclusion criteria (196 humeri). The mean clinical follow-up period was 2.6 years. Most fractures were Cofield B (42%), followed by C (27%), and A (12%); 19% were not classified. Forty-two percent of index implants were reverse total shoulders, 27% anatomic total shoulders, 16% hemiarthroplasties, and 1% resurfacing; implant design was not reported for 14%. The average time from index procedure to fracture was 2.9 years. One hundred sixty-seven (85%) fractures were treated operatively, 26 (13%) were treated nonoperatively, and 3 (2%) were missing information. Overall complication rate was 46%. Nonoperatively treated fractures had a higher complication rate (69% vs. 43%, P = .04) and increased risk of malunion (19% vs. 1%, P = < .001). Nonoperative management failed in 57% of Cofield B fractures. Time to union was shorter in the ORIF group than the revision arthroplasty group (24 weeks vs. 30 weeks, P < .001). Among operatively treated fractures, revision arthroplasty was associated with more complications (61% vs. 25%, P = .04) and higher nonunion rates (22% vs. 0%, P = .008) than ORIF. CONCLUSIONS: Complications may be more frequent than previously understood. With a 70% healing rate, nonoperative management is a viable treatment option, but should be weighed against high risk of complications and need for future procedures, especially in Cofield B fractures. Treatment with ORIF is associated with a higher union rate and fewer complications than revision arthroplasty.
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Abstract Total hip arthroplasty (THA) is a successful surgery in the treatment of hip pain, but there are potential complications, of which dislocation is one of the most common. Dislocation management is a challenging problem that requires a multimodal approach, and the use of dual mobility implants is an option. We present a patient with a history of femoral neck fracture who underwent THA with a double mobility implant. On the 18th postoperative day, after a fall to the ground, she developed prosthesis dislocation and had a complication after closed reduction, a subsequent intraprosthetic dislocation. After a radiographic diagnosis, the patient presented mechanical signs of hip flexion caused by a disassociated double mobility implant. The revision surgery was indicated, but the patient chose not to perform the necessary surgical procedure. A careful postoperative study of the radiographs revealed an eccentric femoral head and evidence of disassociated implantation in the surrounding soft tissues. Radiographs after closed reduction of intraprosthetic dislocations should be examined thoroughly.
Resumo A artroplastia total do quadril (ATQ) é uma cirurgia bem-sucedida no tratamento da dor no quadril, mas existem complicações potenciais, das quais a luxação é uma das mais comuns. O gerenciamento das luxações é um problema desafiador que requer uma abordagem multimodal, e o uso de implantes de mobilidade dupla é uma opção. Apresentamos uma paciente com história de fratura do colo do fêmur que foi submetida a ATQ com um implante de dupla mobilidade. No 18° dia pós-operatório, após queda ao solo, a paciente evoluiu com luxação da prótese e teve uma complicação após redução fechada, uma luxação intraprotética subsequente. Após um diagnóstico radiográfico, a paciente apresentou sinais mecânicos na flexão do quadril causados por um implante de mobilidade dupla desassociado. A cirurgia de revisão foi indicada, mas a paciente optou por não realizar o procedimento cirúrgico necessário. O estudo pós-operatório cuidadoso das radiografias revelou uma cabeça femoral excêntrica e evidências do implante desassociado nos tecidos moles circundantes. As radiografias após a redução fechada das luxações intraprotéticas devem ser examinadas minunciosamente.
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INTRODUCTION: Periprosthetic fractures in total hip arthroplasty (THA) have been well described and studied. However, there is a lack of reports on ipsilateral pubic ramus fractures during THA due to the rare occurrence of such fractures and ambiguity of symptoms. With the use of postoperative computed tomography (CT) examinations, we have identified that asymptomatic ipsilateral pubic ramus fractures occur frequently during THA. This study aims to evaluate the incidence, location, clinical outcomes, and risk factors of ipsilateral pubic ramus fractures during THA. METHODS: From May 2022 to March 2023, a single surgeon performed 203 THAs in 183 patients at a single institution. All patients underwent postoperative CT scans three days after THA. The patients with ipsilateral pubic ramus fractures were followed up for a minimum of six months. Basic demographics, osteoporosis, general conditions of the operations, and outcomes of THA were investigated in all patients. RESULTS: Twenty-two cases (10.8%) of ipsilateral pubic ramus fractures were identified on postoperative CT scans. All fractures were located near the origin of the superior or inferior pubic ramus. Five fractures were detected on simple postoperative radiographs. The fractures did not cause any further complications at a minimum of six-month postoperative follow-up. Univariate and multivariate analyses did not identify any risk factors associated with these fractures. CONCLUSIONS: Although the incidence of ipsilateral pubic ramus fractures during THA is high, treatment is not required as they do not cause any significant clinical symptoms or affect the prognosis of THA. However, the possibility of occurrence of these fractures must be explained to the patients before surgery.
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Artroplastia de Reemplazo de Cadera , Hueso Púbico , Tomografía Computarizada por Rayos X , Humanos , Artroplastia de Reemplazo de Cadera/efectos adversos , Hueso Púbico/lesiones , Hueso Púbico/diagnóstico por imagen , Femenino , Masculino , Anciano , Persona de Mediana Edad , Anciano de 80 o más Años , Fracturas Periprotésicas/epidemiología , Fracturas Periprotésicas/etiología , Fracturas Periprotésicas/diagnóstico por imagen , Fracturas Periprotésicas/cirugía , Factores de Riesgo , Incidencia , Adulto , Estudios Retrospectivos , Complicaciones Intraoperatorias/epidemiología , Complicaciones Intraoperatorias/etiologíaRESUMEN
INTRODUCTION: With a progressive rise in the number of total hip arthroplasties (THA) over the past decades, the proportion of patients sustaining peri-prosthetic fractures (PPF) has been substantially increasing. In this context, the need for clearly understanding the factors predisposing patients to PPF following THA and the impact of these adverse complications on the overall healthcare burden cannot be understated. MATERIALS AND METHODS: Based upon the Nationwide Inpatient Sample (NIS) database, the patients who underwent THA in the United States between 2016 and2019 (with ICD-10 CMP code) were identified. The patients were divided into 2 groups; group A - patients who sustained PPF and group B - those who did not. The information about the patients' demographic profile, medical comorbidities; and hospital admission (including length of stay and expenditure incurred) were analysed; and compared between the 2 groups. RESULTS: Overall, 367,890 patients underwent THA, among whom 4,425 (1.2%) sustained PPF (group A). The remaining patients were classified under group B (363,465 patients). On the basis of multi-variate analysis (MVA), there was a significantly greater proportion of females, elderly patients, and emergent admissions (p < 0.001) in group A. The length of hospital stay, expenditure incurred and mortality were also significantly higher (p = 0.001) in group A. Based on MVA, Down's syndrome (odd's ratio 3.15, p = 0.01), H/O colostomy (odd's ratio 2.09, p = 0.008), liver cirrhosis (odd's ratio 2.01, p < 0.001), Parkinson's disease (odd's ratio 1.49, p = 0.004), morbid obesity (odd's ratio 1.44, p < 0.001), super obesity (odd's ratio 1.49, p = 0.03), and H/O CABG (coronary artery bypass graft; odd's ratio 1.21, p = 0.03) demonstrated significant association with PPF (group A). CONCLUSION: Patients with PPF require higher rates of emergent admission, longer hospital stay and greater admission-related expenditure. Female sex, advanced age, morbid or super obesity, and presence of medical comorbidities (such as Down's syndrome, cirrhosis, Parkinson's disease, previous colostomy, and previous CABG) significantly enhance the risk of PPF after THA. These medical conditions must be kept in clinicians' minds and close follow-up needs to be implemented in such situations so as to mitigate these complications.
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Artroplastia de Reemplazo de Cadera , Tiempo de Internación , Fracturas Periprotésicas , Humanos , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Femenino , Masculino , Anciano , Persona de Mediana Edad , Fracturas Periprotésicas/epidemiología , Fracturas Periprotésicas/cirugía , Fracturas Periprotésicas/etiología , Estados Unidos/epidemiología , Tiempo de Internación/estadística & datos numéricos , Factores de Riesgo , Anciano de 80 o más Años , Adulto , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
Introduction: With the increasing incidence of total knee arthroplasty (TKA), there is an expected rise in rate of periprosthetic fractures in the coming years. It is unclear how the outcomes of patients with distal femur fractures (DFF) and a total knee arthroplasty compare to patients of the same age group with native knees (NK). Materials and methods: A retrospective review was completed for distal femur fractures treated with surgical fixation from January 2019-March 2021. We excluded patients <50 years old, non-ambulatory patients, revision surgeries, and patients with less than 90 days of follow-up. A chart review was performed to collect age, gender, BMI, smoking status, American Society of Anesthesiology (ASA) classification, fracture type, fixation method, time to full weight bearing, and complications. Comparisons between the TKA vs native knee groups were performed using t-test, chi-square, and Fisher's exact test where appropriate. Results: 138 patients were included in our study with a mean age of 74 years. 69 DFF ipsilateral to a TKA were included in the study group and 71 DFF were included in the native knee group. Age, sex, BMI, smoking status, and ASA class were similar between the groups. All patients with periprosthetic femur fractures had 33A AO/OTA fracture classification. Patients with native knees were more likely to receive dual implant fixation, 15.5% compared to 4.3% (p = 0.02). Full weight bearing was achieved at 8.5 vs 8.6 weeks between the NK and TKA groups (p = 0.64). The complication rate was 16.9% in the NK group vs. 7.2% in the TKA group (p = 0.21). Conclusion: Patients with periprosthetic femur fractures have similar time to weight bearing and complications rate with patients with distal femur fracture in native knees. We found a higher utilization rate of dual implant fixation in the native knee group.
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PURPOSE: There is a global trend of increased periprosthetic fractures due to the growing number of arthroplasty procedures. The present study assessed the impact of factors such as time to surgery and type of surgery on the outcomes, which have been seldom evaluated for periprosthetic fractures. METHODS: An observational study was conducted on consecutive 87 patients within an NHS district hospital trust in the UK. Patients who underwent a complete hip replacement prior to the fracture, received fixation therapy, or underwent revision surgery within the specified time were screened. Patients were grouped in two ways: based on time to surgery and based on surgery type. Logistic regression models were performed to assess for statistically significant differences in post-operative complication, 30-day, and 1-year mortality rates between groups, whilst adjusting for age, gender, and ASA grade. RESULTS: Forty-one patients underwent open reduction and internal fixation (ORIF), 29 patients underwent revision arthroplasty, and 17 patients were subjected to both, ORIF and revision arthroplasty. Sixty of the 87 patients were operated on > 48 h of injury. The median hospital stay was significantly lower in the ORIF plus revision arthroplasty group, versus other surgical groups (p < 0.05) whilst it was significantly higher in the group of patients who underwent surgery after 48 h of injury (p < 0.05). Numerically higher mortality was noted in the revision arthroplasty group (31.03%, p > 0.05). The group that was operated after 48 h of injury showed greater mortality but was comparable to the other group (25% vs. 14.81%, p > 0.05). For post-operative complications, none of the variables were significantly predictive (p > 0.05). However, for 30-day mortality, ASA grade (p = 0.04) and intra-operative complications (p = 0.0001) were significantly predictive. Additionally, for 1-year mortality, ASA grade (p = 0.004) was noted to be significantly predictive. CONCLUSION: Revision and delayed periprosthetic fracture management (> 48 h after injury) group showed a numerically greater mortality risk; however, this finding was not statistically significant. ASA grading at baseline is predictive of mortality for periprosthetic fractures.
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Artroplastia de Reemplazo de Cadera , Fijación Interna de Fracturas , Tiempo de Internación , Fracturas Periprotésicas , Complicaciones Posoperatorias , Reoperación , Humanos , Femenino , Masculino , Artroplastia de Reemplazo de Cadera/métodos , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/mortalidad , Reoperación/estadística & datos numéricos , Fracturas Periprotésicas/cirugía , Fracturas Periprotésicas/mortalidad , Fracturas Periprotésicas/etiología , Anciano , Reino Unido/epidemiología , Fijación Interna de Fracturas/métodos , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/mortalidad , Tiempo de Internación/estadística & datos numéricos , Anciano de 80 o más Años , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/etiología , Fracturas de Cadera/cirugía , Fracturas de Cadera/mortalidad , Persona de Mediana Edad , Tiempo de Tratamiento/estadística & datos numéricos , Resultado del Tratamiento , Reducción Abierta/métodos , Factores de Tiempo , Medicina EstatalRESUMEN
PURPOSE: The purpose of this study is to compare the difference of results between two methods of femoral box osteotomy adopted by two designs of posterior stabilized total knee prostheses. PATIENTS AND METHODS: Retrospective analysis of the results of two groups of patients operated upon using two primary PS TKA systems, PFC Sigma (DePuy Synthes, Johnson and Johnson®) and Genesis II prosthesis (Smith and Nephew®), with an average of five year follow-up was done. Group 1 included 152 knees in 121 patients and group 2 included 122 knees in 111 patients. The average follow-up period in both groups was five years. The box osteotomy method depends on bone saw in group 1, and bone reamer in group 2. RESULTS: The KSS score of group 2 was better in the first six months postoperatively. Then, no significant differences were seen in the remaining follow-up visits. The risk of periprosthetic fractures was significantly higher in group 1 (p-value 0.040). Survival analysis showed a significantly shorter time for reoperation in group 1 than in group 2 as described by log-rank test, (p < 0.006). CONCLUSION: The method of box cutting has an impact on the function and longevity of posterior stabilized primary knee implants. The risk of periprosthetic fractures can be reduced by proper patient selection, decreasing the box sizes, and development of more "controlled" box osteotomy instruments.
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Artroplastia de Reemplazo de Rodilla , Prótesis de la Rodilla , Osteoartritis de la Rodilla , Fracturas Periprotésicas , Humanos , Artroplastia de Reemplazo de Rodilla/métodos , Estudios Retrospectivos , Articulación de la Rodilla/cirugía , Estudios de Seguimiento , Fracturas Periprotésicas/cirugía , Prótesis de la Rodilla/efectos adversos , Osteoartritis de la Rodilla/cirugía , Osteotomía/efectos adversos , Osteotomía/métodos , Rango del Movimiento ArticularRESUMEN
Periprosthetic fractures are a serious complication of joint replacement surgery. With the growing prevalence of reverse total shoulder arthroplasty (RTSA), the incidence of relatively uncommon periprosthetic humeral fractures has increased. Here, we present the unique case of a 74-year-old woman who developed atrophic non-union after plate osteosynthesis for a periprosthetic fracture associated with RTSA. Fixation failure was evident 3 months after the surgical intervention; the patient underwent a 3-month course of arm sling immobilization. However, bone resorption continued, and varus angulation of the fracture developed. In this case, surgical strategy involved the use of long proximal humerus internal locked system plate (DePuy Synthes, Paoli, PA, USA), augmented with autologous iliac bone graft and allogenic humerus structural bone graft with the "bamboo support technique", fixed with Cable System (DePuy Synthes, Paoli, PA, USA). No reports have addressed the management of failed periprosthetic fractures using allogeneic humeral strut bone grafts. This report aims to fill the gap by presenting a novel surgical technique for the management of periprosthetic fractures associated with RTSA in case of treatment failure.
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BACKGROUND: The purpose of this study was to determine the prevalence of unexpected positive cultures noted at the time of revision surgery for periprosthetic fracture (PPF) after total hip or knee arthroplasty. Moreover, we evaluated whether this finding should be considered clinically significant and what type of treatment, if any, was required. METHODS: This was a single-center retrospective review of 270 patients undergoing surgery for PPFs from December 2010 to December 2021. Exclusion criteria included: open fractures; history of infection at fractured joint; non-operatively treated patients; and intraoperative fractures. The primary end point was the prevalence of unexpected positive cultures noted at the time of revision surgery. This was defined as one or more positive cultures in a PPF that the surgeon had preoperatively classified as aseptic according to the 2018 International Consensus Meeting. Data collection included patient demographics, medical histories, preoperative investigations, postoperative microbiology, and treatment. RESULTS: During the study period, 159 patients were admitted with PPFs of the hip and 61 with PPFs of the knee. The mean age was 70 years (range, 32 to 93 years). Unexpected positive cultures were diagnosed postoperatively in 15 patients (6.8%; 10 hips, 5 knees). The most prevalent organism was Staphylococcus epidermidis (35.0%). Of those 15 patients, 6 required a surgical revision for infection. None of the patient-related risk factors were found to be associated with an increased risk of unexpected positive cultures. The comparison between infected and noninfected patients showed a significant association between preoperative C-reactive protein >10 mg/mL (P = .04), loose implant (P = .07), and infection. CONCLUSIONS: The prevalence of unexpected positive cultures was 6.8% in our study cohort. Although surgical treatment may be required, the majority of patients seem to require no treatment. Larger series are required to investigate the clinical importance of this rare finding. LEVEL OF EVIDENCE: III.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Fracturas Periprotésicas , Infecciones Relacionadas con Prótesis , Reoperación , Humanos , Fracturas Periprotésicas/cirugía , Fracturas Periprotésicas/epidemiología , Fracturas Periprotésicas/etiología , Anciano , Persona de Mediana Edad , Femenino , Estudios Retrospectivos , Masculino , Artroplastia de Reemplazo de Rodilla/efectos adversos , Anciano de 80 o más Años , Reoperación/estadística & datos numéricos , Artroplastia de Reemplazo de Cadera/efectos adversos , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/epidemiología , Adulto , Staphylococcus epidermidis/aislamiento & purificación , Prótesis de la Rodilla/efectos adversos , Prótesis de la Rodilla/microbiología , PrevalenciaRESUMEN
BACKGROUND: Femoral neck fractures are common in individuals over 65, necessitating quick mobilization for the best outcomes. There's ongoing debate about the optimal femoral component fixation method in total hip arthroplasty (THA) for these fractures. Recent U.S. data shows a preference for cementless techniques in over 93% of primary THAs. Nonetheless, cemented fixation might offer advantages like fewer revisions, reduced periprosthetic fractures, lesser thigh pain, and enhanced long-term implant survival for those above 65. This study compares cementless and cemented fixation methods in THA, focusing on postoperative complications in patients aged 65 and older. METHODS: We analyzed a national database to identify patients aged 65+ who underwent primary THA for femoral neck fractures between 2016 and 2021, using either cementless (n = 2,842) or cemented (n = 1,124) techniques. A 1:1 propensity-matched analysis was conducted to balance variables such as age, sex, and comorbidities, resulting in two equally sized groups (n = 1,124 each). We evaluated outcomes like infection, venous thromboembolism (VTE), wound issues, dislocation, periprosthetic fracture, etc., at 90 days, 1 year, and 2 years post-surgery. A P-value < 05 indicated statistical significance. RESULTS: The cemented group initially consisted of older individuals, more females, and higher comorbidity rates. Both groups had similar infection and wound complication rates, and aseptic loosening. The cemented group, however, had lower periprosthetic fracture rates (2.5 versus 4.4%, P = .02) and higher VTE rates (2.9 versus 1.2%, P = .01) at 90 days. After 1 and 2 years, the cementless group experienced more aseptic revision surgeries. CONCLUSIONS: This study, using a large, national database and propensity-matched cohorts, indicates that cemented femoral component fixation in THA leads to fewer periprosthetic fractures and aseptic revisions, but a higher VTE risk. Fixation type choice should consider various factors, including age, sex, comorbidities, bone quality, and surgical expertise. This data can inform surgeons in their decision-making process.
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Artroplastia de Reemplazo de Cadera , Cementos para Huesos , Fracturas del Cuello Femoral , Complicaciones Posoperatorias , Humanos , Artroplastia de Reemplazo de Cadera/métodos , Artroplastia de Reemplazo de Cadera/efectos adversos , Anciano , Femenino , Masculino , Fracturas del Cuello Femoral/cirugía , Anciano de 80 o más Años , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Fracturas Periprotésicas/etiología , Fracturas Periprotésicas/epidemiología , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Resultado del Tratamiento , Prótesis de Cadera/efectos adversos , Fijación Interna de Fracturas/métodos , Fijación Interna de Fracturas/instrumentación , Fijación Interna de Fracturas/efectos adversosRESUMEN
BACKGROUND: Hip and knee implants can be either fixated without cement, press-fit, or with bone cement. Real-world data from arthroplasty registers, as well as studies, provide a broad database for the discussion of cemented versus uncemented arthroplasty procedures. OBJECTIVES: What is the recommendation for cemented or cementless anchorage of hip and knee implants based on the current evidence from international arthroplasty registries and meta-analyses? METHODS: A recommendation is generated by means of a direct comparison of data from the arthroplasty registries of eight different countries (USA, Germany, Australia, UK, Sweden, Norway, New Zealand, and The Netherlands), the comparison of 22 review studies and meta-analyses based on registry data, as well as the evaluation of the recommendation of healthcare systems of different nations. For this purpose, reviews and meta-analyses whose results were statistically significant were selected, as were the annual reports of the arthroplasty registries that were current at the time of writing. RESULTS: For knee endoprostheses, a long survival time, as well as a lower risk of revision can be achieved with the help of cemented anchorage with antibiotic-laden bone cement. In patients aged 70 years and older, cemented anchorage of the hip stem implant significantly reduces the risk of intraoperative or postoperative periprosthetic fracture (times four), this applies both to elective total hip arthroplasties (TEPs) and to hemiarthroplasty after femoral neck fractures. Antibiotic-loaded bone cement significantly (pâ¯= 0.041) reduces the risk of periprosthetic infection, especially in patients with femoral neck fractures. CONCLUSIONS: Total knee replacement with antibiotic-loaded bone cement is well established in Germany and evidence based. Registry data and meta-analyses recommend cemented fixation of the hip stem in older patients-in Germany the evidence-based recommendations must still be transferred to daily practice.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Fracturas del Cuello Femoral , Prótesis de Cadera , Humanos , Anciano , Anciano de 80 o más Años , Cementos para Huesos/uso terapéutico , Falla de Prótesis , Reoperación , Diseño de Prótesis , Artroplastia de Reemplazo de Cadera/efectos adversos , Antibacterianos , Fracturas del Cuello Femoral/cirugíaRESUMEN
Objective:To analyze the clinical efficacy of internal fixation and prosthesis revision in the treatment of periprosthesis fracture after total knee arthroplasty.Methods:A total of 35 patients (35 knees) with periprosthetic fractures after total knee arthroplasty were retrospectively analyzed from January 2008 to January 2022 in the Department of Orthopaedics, West China Hospital, Sichuan University, including 13 males and 22 females, aged 71.4±4.1 years (range, 62-81 years). Left knee 19 cases, right knee 16 cases. There were 20 cases of Rorabeck type II and 15 cases of Rorabeck type III. The initial replacement was performed using a fixed platform post-stabilized knee prosthesis, which was fixed with bone cement. Patients with Rorabeck type II were treated with internal fixation alone (internal fixation group) and patients with Rorabeck type III underwent revision with replacement prosthesis (revision group). The Hospital for Special Surgery (HSS) score, range of motion (ROM) of knee joint, alignment of lower extremity and incidence of postoperative complications were compared between the two groups.Results:All patients successfully completed the operation and were followed up for 5.2±3.6 years (range, 1-12 years). Intraoperative blood loss was 680±102 ml (range, 420-1100 ml). The operative time in the internal fixation group was 105±17 min, which was less than 140±21 min in the revision group, and the difference was statistically significant ( t=-5.450, P<0.001). There was no complication of nerve or blood vessel injury during the operation. Five cases in the internal fixation group had unsatisfactory lower extremity force lines (>3° deviation from normal) after surgery, and all lower extremity force lines in the revision group were satisfied, and the difference in the satisfaction rate of lower extremity force lines between the two groups was not statistically significant ( P=0.057). The fracture healing time, knee ROM and HSS scores at the last follow-up were 5.1±1.3 months, 86°±5° and 84±5 in the internal fixation group and 4.8±1.5 months, 83°±6° and 82±4 in the revision group. One case in the revision group was diagnosed postoperatively with periprosthetic infection with pathogen culture suggestive of Candida albicans, recurrent anterior knee sinus tracts and patellar ectasia, which progressed to osteomyelitis, and mid-thigh amputation was performed 1 year after revision. Conclusion:The stability of prosthesis is an important reference for the treatment of periprosthetic fractures after total knee arthroplasty. Strong internal fixation in patients with unloosened prosthesis and revision with replacement of prosthesis in patients with loose prosthesis can achieve good knee joint function.
RESUMEN
BACKGROUND: Osteosynthesis for geriatric femoral pertrochanteric fractures using the linear compression integrated screw intramedullary nail system (INTERTAN™) has become popular. Nonetheless, cases of perioperative peri-implant fractures have been reported following this surgical technique. The factors responsible for this complication remain unclear. Therefore, we investigated perioperative peri-implant fracture risk factors and incidence, as well as overall outcomes, using the INTERTAN™ system for geriatric femoral pertrochanteric fractures. METHODS: We retrospectively reviewed 98 consecutive patients with geriatric femoral pertrochanteric fractures after INTERTAN™ fixation, with at least a 12-month follow-up period between May 2020 and April 2022 at a single medical institute. The patients' demographic characteristics, fracture pattern, quality of reduction, quality of fixation, nail length, morphology of the femur, and perioperative complications were recorded and analyzed. RESULTS: Among the 98 patients, 92 achieved union during follow-up. Twelve perioperative peri-implant fractures (12.2%) were recorded, all of which occurred during or within 1 month of osteosynthesis. Except for one patient who underwent re-osteosynthesis, the others underwent nonoperative treatment, and all achieved union. Multiple regression analysis revealed morphology of the femur with low-lesser trochanter width (odds ratio (OR) 0.532, 95% confidence interval (CI) 0.33-0.86, p = 0.01) to be the only factor contributing to perioperative peri-implant fractures. When the Youden index was used, the optimal cut-off value was 20.2 mm of low-lesser trochanter width. Low-lesser trochanter width < 20.2 mm was found to be a potential factor causing perioperative peri-implant fractures (OR 17.81, 95% CI 1.67-19.76, p = 0.017). CONCLUSIONS: Morphology of the femur with a low-lesser trochanter width smaller than 20.2 mm was found to be the only potential contributor to perioperative peri-implant fractures when using INTERTAN™ for geriatric femoral pertrochanteric fractures. Care should be taken during osteosynthesis, focusing not only on the fracture site but also on the femoral cortex around the implant. Although perioperative peri-implant fractures were observed within one month following osteosynthesis, the majority of these cases were effectively treated without surgical intervention.
Asunto(s)
Fracturas del Fémur , Fijación Intramedular de Fracturas , Fracturas de Cadera , Fracturas Periprotésicas , Humanos , Anciano , Fracturas Periprotésicas/etiología , Estudios Retrospectivos , Clavos Ortopédicos/efectos adversos , Fracturas del Fémur/cirugía , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/métodos , Tornillos Óseos/efectos adversos , Fémur , Fijación Intramedular de Fracturas/efectos adversos , Fracturas de Cadera/cirugía , Fracturas de Cadera/complicacionesRESUMEN
OBJECTIVE: To study the impact of reorganization of European hospitals during the most severe phase of the SARS-CoV-2 pandemic on standards of care and early outcomes in patients with periprosthetic fractures. MATERIAL AND METHODS: We reviewed available data collected from 14 hospitals in Northern Italy during the quarantine period between March 9 and May 4, 2020. The study included all patients admitted to emergency departments with periprosthetic fractures and scheduled for surgery within a 2-month period. Periprosthetic fractures were classified according to the Uniform Classification System (UCS). Distribution normality was tested using the Kolmogorov-Smirnov test. Accordingly, data were described as non-parametric. Statistical analysis was performed using the Microsoft Excel v. 16.0. RESULTS: In total, 1390 patients admitted to the Department of Orthopedics and Traumatology for emergency care throughout the follow-up period including 38 (2.7%) ones with periprosthetic fractures. There were 12 (31.5%) men and 26 (68.5%) women. Mean age was 81 years (range 70-96). Screening for SARS-CoV-2 by swab was performed in 23 out of 38 patients (60.5%) at admission. It was positive in 2 (5.3%) cases. Three out of thirty-eight patients (7.9%) were diagnosed with COVID-19 due to clinical signs. Of these, 2 patients were diagnosed with COVID-19 before surgery, 3 patients - after surgery. Although the study period coincided with quarantine, the number of admissions for periprosthetic fractures (3%) was similar to that in 2019 and accounted for 3% of the total number of visits to the traumatology and orthopedics departments. CONCLUSION: The study revealed no obvious changes in hospitalizations for periprosthetic fractures despite social restrictions during the first wave of the COVID-19 pandemic. In emergency, hospitals were still able to provide standard care for patients with periprosthetic fractures despite significant amount of resources redirected for the pandemic.
Asunto(s)
COVID-19 , Fracturas Periprotésicas , Masculino , Humanos , Femenino , Anciano , Anciano de 80 o más Años , COVID-19/epidemiología , SARS-CoV-2 , Fracturas Periprotésicas/cirugía , Pandemias , Europa (Continente)/epidemiologíaRESUMEN
Background: Acromion stress fractures (ASF) or scapular spine fractures (SSF) following reverse total shoulder arthroplasty (RTSA) are common complications with impaired clinical outcome. The underlying biomechanical factors remain unclear. The aim of this study was to evaluate basic demographic and radiographic parameters predicting occurrence of different types of ASF/SSF in a large single-center study cohort. Methods: A total of 860 RTSA (805 patients) with available minimum follow-up of 2 years were implanted between 2005 and 2018 at a tertiary academic center. All RTSA with subsequent ASF/SSF (n = 45 in 43 shoulders [42 patients, 5%]) were identified and classified as Levy I to III. Predictive demographic, surgical, and radiographic factors were evaluated for each subtype and compared to the control group (817 RTSA, 763 patients). The radiographic analysis included critical shoulder angle, lateralization shoulder angle (LSA), distalization shoulder angle (DSA), acromio-humeral distance (ACHD), acromial thickness, deltoid tuberosity index, deltoid length, and center of rotation. Results: Of the 45 ASF/SSF in 42 patients, 8 were classified as Levy I, 21 as Levy II, and 16 as Levy III. Demographic analysis revealed indication as risk factor for Levy I fractures, higher American Society of Anesthesiologists score as risk for Levy type II fractures and higher age as risk factor for Levy type III fractures. None of the measured radiographic parameters were predictive for occurrence of Levy type I and Levy type II ASF. However, analysis of Levy III SSF revealed a higher postoperative LSA (89° ± 10° vs. 83° ± 9°, P = .015), a lower postoperative DSA (45° ± 8° vs. 53° ± 12°, P = .002), less distalization (ACHD of 33 ± 8 mm vs. 38 ± 10 mm, P = .049), and a more medial center of rotation preoperatively (COR-LA 16 ± 8 mm vs. 12 ± 7 mm, P = .048) as predictive radiographic factors. Conclusion: The present analysis showed a significant association of higher postoperative LSA, lower DSA, a lower ACHD, and higher age as predictive factor only for Levy type III fractures. Some of these factors can be surgically influenced and this knowledge can be of value for preoperative planning and surgical execution to avoid these complications.