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Design: Retrospective study., Setting: Level I academic Trauma Center., Patient Selection Criteria: Adult patients with femoral shaft fractures in which a bilateral computed-tomography (CT) scan of both femurs was performed, with a two years minimal follow-up., Outcome Measures and Comparisons: Criteria related to the patient and the fracture were studied. We fixed the following angles, i.e. 10° and 15°, as references for calculating the RM., Competing Interests: Declarations No funds, grants, or other support were received during the preparation of this manuscript. Competing interests Non-financary interests: author Xavier Flecher serves as a consultant for Zimmer Biomet med education., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Introduction: Cementless fixation has become increasingly popular in hip arthroplasty due to its shorter operation time, easier technique, biologic fixation, and avoidance of bone cement implantation syndrome compared to cemented fixation. However, intraoperative periprosthetic femoral fracture (IOPFx) is a disconcerting complication during cementless hip arthroplasty. Our purpose was to identify the features of cementless stem that increase the risk of IOPFx during primary hip arthroplasty., Materials and Methods: We retrospectively reviewed all 4806 hip arthroplasties that was performed in a single institution from May 2003 to December 2020. Age at the index arthroplasty, sex, body mass index, physical status, ambulatory function, side of the operation, operational history, cause of the index arthroplasty, type of arthroplasty, surgical approach, surgeon, implant information, and events during the operation were investigated. The shoulder geometry and length of stem were also reviewed. The event of interest was narrowed down to IOPFx among various records of intraoperative events., Results: We found IOPFx of 2.6% among all the hips operated with cementless stem. In the multivariable analysis, female (OR = 1.52), childhood hip disease (OR = 2.30), stove-pipe femur (OR = 2.43), combined approach (OR = 2.60), and standard length of stem (OR = 1.59) were found to be significant risk factors of IOPFx., Conclusions: In conclusion, a stem with a standard length is significantly associated with risk of IOPFx compared to a shortened stem. These findings highlight the importance of careful consideration in terms of the risk of IOPFx when standard length cementless stem is chosen., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: This study explored the incidence of IRCs used in the procedures of the femur in children with osteogenesis imperfecta (OI) and investigated the independent risk factors of IRCs., Methods: Three hundred eight-eight cases of surgical data about children with OI were included, who were treated with plate, elastic nail, Kirschner wire and telescopic rod. The choice of different procedures depended on the age of children, the status of femur and the availability of devices. Patient demographics and major IRCs were recorded to compare the outcomes of the four procedures. Then, Cox proportional hazard regression was used to analyse the independent risk factors of IRC, and subgroup analysis was applied to further verify the above results., Results: The total incidence of IRC in the four groups was 90.1% (191/212) for plate, 96.8% (30/31) for Kirschner wire, 87.7% (57/65) for elastic nail and 30.0% (24/80) for telescopic rod. The incidence of IRC in the telescopic rod was lower than that in plate, elastic nail and Kirschner wire (P < 0.001). Cox proportional hazard regression analysis confirmed that procedure was the independent risk factor of IRC (HR, 0.191; 95% CI, 0.126-0.288; P < 0.001), fracture (HR, 0.193; 95% CI, 0.109-0.344; P < 0.001) and deformity (HR, 0.086; 95% CI, 0.027-0.272; P < 0.001). In addition, age of surgery was the independent risk factor of fracture (HR, 0.916; 95% CI, 0.882-0.952; P < 0.001) and deformity (HR, 1.052; 95% CI, 1.008-1.098; P = 0.019). Subgroup analysis confirmed that age of surgery, gender, classification, preoperative state and angle did not affect the effect of telescopic rod on reducing the risk of IRCs., Conclusions: In our cohort, lower incidence of IRCs was observed in telescopic rod group compared with plate, Kirschner wire and elastic nail. Procedure and age of surgery were independent risk factors of fracture. Likewise, procedure and age of surgery were independent risk factors of deformity, and procedure was independent risk factors of IRC., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Background: Femoral stem fracture following total hip arthroplasty (THA) is an infrequent but nevertheless devastating complication, with an increasing worldwide prevalence as demand for primary THA continues to increase. The aim of this study was to perform a systematic review and meta-analysis of risk factors for femoral stem fracture to help identify at risk patients., Methods: A systematic search was conducted on EMBASE, MEDLINE and AMED to identify relevant studies. Data regarding study design, source, population, intervention, and outcomes was collated. Data extraction was performed on a custom form generated using Cochrane recommended methodology and analysis of risk factors performed including odds ratios (ORs) with 95% confidence intervals (CIs)., Results: A total of 15 studies reporting a total of 402 stem fractures in 49 723 THAs were identified. The median time from index procedure to stem fracture was 68 months (IQR 42.5-118) whilst mean age at index surgery was 61.8 years (SD 6.9). Male gender (OR = 3.27, 95% CI = 2.59-4.13, p < 0.001), patient weight above 80 kg (OR = 3.55, 95% CI = 2.88-4.37, p < 0.001), age under 63 years (OR = 1.22, 95% CI = 1.01-1.49, p < 0.001), varus stem alignment (OR = 5.77, 95% CI = 3.83-8.7, p < 0.001), use of modular implants (OR = 1.95, 95% CI = 1.56-2.44, p < 0.01) and undergoing revision arthroplasty (OR = 3.33, 95% CI = 2.70-4.1, p < 0.001) were significant risk factors for prosthetic stem fracture. A risk window of 15 years post-surgery was identified., Conclusions: This review concludes that patient weight, younger age, male sex, varus stem alignment, revision arthroplasty and use of modular stems are significant risk factors for femoral stem fracture. Modifying these risk factors where possible may help reduce incidence of femoral stem fracture in at risk patients., (© 2024. The Author(s).)

Introduction: The treatment of Vancouver B2 periprosthetic fractures after hip arthroplasty is still a matter of debate. Revision Arthroplasty (RA) was long thought to be the treatment of choice, however several recent papers suggested that Open Reduction and Internal Fixation (ORIF) is a viable option for selected B2 fractures. Complication rates of 14-26% have been reported following surgical treatment of B2 fractures. No significant difference between RA and ORIF in the complication rates nor in the functional outcome was observed., Method: We conducted a retrospective analysis of 97 consecutive Vancouver B2 fractures treated according to the algorithm at our institution from 2007 to 2020 and recorded complications and patient specific data., Result: From the 97 patient, 45 fractures were treated with RA while 52 fractures were treated with ORIF. Thirteen patients in the RA group had a complication that needed revision (28%) and 11 patients in the ORIF group needed revision (21%). There was no significant difference between complication rates. The reason for failure in the 13 RA patients were infection (n = 4), stem subsidence (n = 1), refracture after a new fall (n = 3), secondary dislocation of the greater trochanter (n = 1) and dislocation (n = 4). The reason for failure in the 11 ORIF patients that were revised were infection (n = 5), persistent symptomatic stem loosening (n = 3) and refracture (n = 3) after a new fall., Conclusion: ORIF can be used to revise cemented and non-cemented shafts in more than half of Vancouver B2 fractures with no difference in complication rates when compared to RA. A periprosthetic fracture around the hip has a 21-28% risk of a re-operation after revision surgery with infection and re-fracture after a new fall being the most frequent cause of re-operation., (© 2024. The Author(s).)

Introduction: Intramedullary (IM) nailing is the treatment of choice for femoral shaft fractures, but nonunion rates have been reported to be as high as 12%. Surgical interventions for nonunion involve exchange nailing or plate augmentation. Recently, a combined treatment of exchange nailing and plate augmentation has demonstrated good results, but its comparative effectiveness remains unclear. This study aimed to compare the clinical and radiographic outcomes of three different surgical interventions for atrophic femoral shaft nonunion, and investigate the factors that affect bone healing after reoperation., Materials and Methods: A retrospective study was conducted at five university hospitals involving 149 patients with aseptic atrophic nonunion after IM nailing. These patients underwent reoperation with plate augmentation, exchange nailing, or combined treatment. Clinical and radiographic outcomes were assessed and compared according to reoperation procedure. Logistic regression analysis was performed to identify factors affecting persistent nonunion after reoperation., Results: Of the cohort, 57 patients underwent plate augmentation, 64 underwent exchange nailing, and 28 received combined treatment. There were no significant differences in patient demographics among the groups. Exchange nailing produced a significantly lower union rate than did the combined treatment (82.8% vs. 100%, p = 0.016), whereas no significant difference was observed in the union rate and time to the union between plate augmentation and the combined treatment. Combined treatment showed the longest operative time and the greatest transfusion requirements. The risk factors for persistent nonunion included age, absence of autogenous bone grafts, and use of an exchange nailing technique., Conclusions: Exchange nailing as a treatment for atrophic femoral shaft nonunion after IM nailing resulted in a lower union rate. The efficacy of the combined treatment requires further study, and persistent nonunion may be influenced by age, bone grafting, and surgical techniques. A comprehensive approach targeting both biological environment and mechanical stability is crucial in the treatment of atrophic femoral shaft nonunion., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: This study aimed to estimate the mortality at various post-operative intervals and explore influential variables for these outcomes in elderly patients with distal femur fractures (DFF)., Methods: A retrospective observational study was conducted across two tertiary care institutions, between 2014 and 2020. The primary outcomes were mortality rates at 30-day, six month, and one year post-surgery. Secondary outcomes included 1-year readmission and reintervention rates along with their correlated complications., Results: A total of 37 DFF in 35 patients was analyzed; average age was 83.6 years (range, 65-98 years). The overall mortality rate at a maximum follow-up of 8.8 years was 74% (26/35 patients). The median survival time was 3.2 years and the survival probability at five years was 27% (95% confidence interval [CI], 13 to 43%). Mortality rates at 30 days, six months, and one year after surgery were 8.6% (3 patients), 23% (8 patients), and 34% (12 patients), respectively. Overall mortality rate was 64% (15/24 patients) for native distal femur fractures, and 92% (13/14 patients) for periprosthetic fractures (p = 0.109). Patients older than 85 years and male gender were identified as risk factors for mortality within the first year post-operatively., Conclusion: Elderly fractures have a high mortality at eight years of follow-up. Mortality at one year was much higher than in other studies of the same nature. We did not find statistically significant differences when comparing native bone fractures with periprosthetic fractures. Factors that impact mortality were being a man, advanced age, elevated index comorbidity, and dementia. There is no relationship between the time to be taken to the surgical procedure and mortality results., (© 2024. The Author(s).)

Introduction: The purpose of this study was to report mid-term clinical and radiographic results after hip arthroplasty revision in Vancouver type B2 femoral periprosthetic fractures (PPFx). Specifical focus of the paper is as follows: (1) the description of a standardized and reproducible surgical technique, (2) functional outcomes presentation and (3) type and number of complications and implants' survival rate analysis., Methods: We retrospectively reviewed all patients treated for hip revision with non-modular tapered fluted titanium stem in patients with Vancouver type B2 femur PPFx at a single institution. At least 18 months' follow-up period was required. Harris Hip Scores and SF-12 were obtained, and radiographical follow-up was performed. Complications were reported and analyzed., Results: The authors included 114 patients (114 hips) with a mean follow-up of 62.8 ± 30.6 months. All patients were treated with Wagner SL revision hip stem (Zimmer-Biomet), metal cerclage wires ± trochanteric plate. The mean HHS and SF-12 score at the last follow-up evaluation were respectively 81.3 ± 9.7 and 32.5 ± 7.6. Seventeen (14.9%) complications occurred. We observed five cases of dislocations, two of periprosthetic joint infections and six cases of new PPFx. The stem-related revision rate for any cause at the final FU was 1.7%, due to PJI. No patients underwent stem revision surgery for aseptic loosening. Fracture healed in all the included patients with a union-rate of 100%. The re-operation rate for any cause was 9.6%, with an implant survival rate for overall failure of 96.5%., Conclusion: The presented standard and reproducible surgical technique obtains optimal clinical and radiological results with limited complication rate at mid-term follow up. Preoperative planning as well as careful intraoperative surgical technique is of a paramount importance., (© 2023. The Author(s).)

Introduction: Fractures of the proximal femur accompanied by a fracture of the femoral shaft are relatively rare, with a reported prevalence between 1 and 12%. Multiple surgical options are available, consisting of treatment with a single implant or with double implants. Controversy exists about the optimal management. A systematic review and pooled analysis were performed to assess the most reliable treatment for bifocal femoral fractures of the femur., Materials and Methods: A literature search was conducted on July 15, 2022. Selected studies were screened on title and abstract by two researchers independently, and full texts were read by both authors. Emphasis was put on adverse events such as postoperative infection, healing complications, malalignment, and functional outcome using either a single implant or double implants., Results: For the proximal femoral fractures, no significant difference could be confirmed for avascular necrosis of the femoral neck (5.1% for single implant and 3.8% for double implants), nonunion (6.4% for single implant and 7.8% for double implants), or varus malalignment (6.6% for single implant and 10.9% for double implants). This study also suggests that the number of implants is irrelevant for complications of the femoral shaft regarding the rates of postoperative infection and healing complications. Pooled rates of bone healing complications were 1.6-2.7-fold higher when patients were treated with a single implant, but statistical significance could not be confirmed. For hardware failure, revision surgery, leg length discrepancy, and functional outcome, no difference between the two groups was found either., Conclusions: The pooled proportions of all postoperative complications had overlapping confidence intervals; thus, no inference about a statistically significant difference on the number of implants used for treating ipsilateral fractures of the femur can be made. Both treatment groups showed a similar functional outcome at the last moment of follow-up, with more than 75% of the patients reporting a good outcome., (© 2023. The Author(s).)

Introduction: The true incidence of periprosthetic femoral fracture (PFF) around cemented polished taper-slip implants remains largely unknown. Registries usually only capture PFFs that result in revision, missing those managed non-operatively or treated by open reduction and internal fixation (ORIF). This study reports the long-term rate of PFF with the original triple-tapered C-stem femoral implant., Materials and Methods: A prospective review of a consecutive series of 500 primary total hip arthroplasties (THAs) performed at a single centre between March 2000 and December 2005, with average follow-up of 15 years (12-19 years)., Results: There were 500 consecutive THAs in 455 patients. Seven PFFs (1.4%) occurred in seven patients at an average of 7.9 years (range 2-11.5) from the primary arthroplasty. Five PFFs were managed by ORIF, one Vancouver B3 fracture was revised for a loose implant and one patient was treated non-operatively. Average age at primary operation was 74 years (67-87) and BMI averaged 27.3 (22-31). There was no typical fracture pattern and no statistically significant associations with patient demographics (age, gender, BMI, diagnosis) or prosthetic details (size, offset, alignment, cement mantle, subsidence). Survivorship to the occurrence of PFF was 99% (97.3-99.6%) at 10 years and 97.8% (95.5-99.0%) at 15., Conclusion: A PFF rate of 1.4% at an average follow-up of 15 years represents the true incidence of PFF with the use of the original triple-tapered C-Stem femoral implant, similar to that of published Exeter series (1.85%) but lower than the CPT (3.3%)., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: The aim of this study was to evaluate the clinical and radiological outcomes of patients treated with the TFN-Advanced™ Proximal Femoral Nailing system (TFNA¸ DePuy Synthes, West Chester, PA) including intra- and postoperative complications., Materials and Methods: All patients with an acute proximal femur fracture consequently treated with a TFNA between September 2014 and December 2018 were evaluated. Clinical and radiological data were assessed for intra- and postoperative complications, including treatment failure. In addition, intra- and postoperative X-rays were used to determine the position of the implant, and any migration, via tip-apex-distance (TAD) and the caput-collum-diaphyseal angle (CCD). The accuracy of the fracture reduction was rated by both observers according to Baumgartners criteria., Results: 275 consecutive patients (mean age 77.5 ± 14.1; 70.2% female) were included. The predominant OTA/AO fracture classification was 31A2 (140 cases, 50.7%). The average surgical time was 69 min (± 39.8). The reduction quality was good in 253 cases (92.0%) and acceptable in 22 cases (8.0%). In 18 cases, a pre-defined primary outcome parameter (6.5%) was recorded after a mean of 8.2 ± 8.0 months. During the observational period, 19 patients (6.9%) required a total of 23 additional surgeries. Implant removal was not considered a failure in the absence of pain. Significant group differences were observed with younger age (p = 0.001), lower Charlson Comorbidity Index (CCI)-score (p = 0.041) and lower rate of osteoporosis (p = 0.015) in the failure group. There were no cases of cut-out or cut-through among the patients who underwent augmentation as part of osteosynthesis., Conclusions: Proximal femur fractures treated with the TFNA show low complication rates and high levels of radiological healing. Implant-related complications might be more common in patients with younger age, a lower CCI-score and lower frequency of osteoporosis. Usage of cement augmentation could potentially be beneficial to reduce postoperative cut-through and cut-out., (© 2022. The Author(s).)

Background: The treatment of periprosthetic femur fractures around a total knee replacement remains a technical challenge for the orthopedic surgeon. Management options include non-operative treatment, plate fixation, intramedullary nailing and distal femur replacement (DFR), with few studies comparing fixation with DFR. This is an up-to-date meta-analysis in the literature to directly compare clinical outcomes between fixation and distal femoral replacement in the treatment of supracondylar periprosthetic femur fractures., Methods: A stratified literature search of the Medline, EMBASE and Cochrane databases was performed. All studies in English language were searched from inception to July 2022. The search was performed with the following MeSH terms: Periprosthetic fracture AND ORIF OR Internal Fixation AND Distal Femur Replacement. The search was conducted using a predesigned search strategy where all eligible literature was critically appraised for methodological quality using the Cochrane collaboration tool. We included Level I, II and III studies comparing fixation with DFR in the treatment of periprosthetic supracondylar femur fractures. Data from eligible studies were extracted by two authors (NP and AR) and a table created which included author, year, sample size, mean age, measured parameters, follow-up period, fracture classification, length of stay (days), mortality rate, revision rate and complication rate., Results: The extracted data were pooled for meta-analysis using RevMan® v5.3.5 software (Nordic Cochrane Centre, Copenhagen, Denmark) and forest plots constructed. A p value < 0.05 was considered statistically significant and confidence intervals (CI) set to 95%. A total of six studies were included in the meta-analysis (n = 406). 153 patients underwent distal femur replacement and 253 patients underwent fixation with a mean follow-up time of 71.4 months. The results of this analysis suggest no statistically significant difference in measured outcomes., Conclusion: The results of this meta-analysis suggest no proven statistically significant difference between DFR and fixation in terms of length of hospital stay, mortality rate, revision rate and complication rate for the treatment of periprosthetic supracondylar femur fractures. Further prospective randomized research may help to define the specific indications for each treatment option which must include fracture configuration. Early functional outcome and cost-effectiveness have yet to be evaluated in the available literature., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Distal femur fractures (DFFx) are highly morbid injuries with a complication rate comparable to hip fractures. Rising rates of total knee arthroplasty (TKA) have led to increasing rates of periprosthetic DFFx (pDFFx). We sought to determine how pDFFx complication rates differed from native DFFx (nDFFx)., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients who sustained pDFFx or nDFFx between 2012 and 2018. Patients were further stratified by operative treatment: open reduction internal fixation (ORIF) or distal femur replacement (DFR). Multivariate logistic regression was used to compare 30-day complication rates between pDFFx versus nDFFx and, among pDFFx patients, ORIF versus DFR or revision TKA (rTKA)., Results: 563 patients with pDFFx and 2259 patients with nDFFx were identified between 2012 and 2018. pDFFx patients had significantly lower rates of ORIF than nDFFx patients (36.4 vs 95.4%, p < 0.001). On multivariate analysis, pDFFx were associated with a higher rate of surgical site complications (OR 2.48, p = 0.009) compared to nDFFx. There were no differences in mortality, reoperations, major complications, rate of blood transfusion, venous thromboembolism and disposition. In patients with pDFFx, patients undergoing DFR/rTKA were more likely to be discharged home versus a rehab facility, compared to those undergoing ORIF (OR 2.62, p < 0.001)., Conclusions: In this first large registry study comparing pDFFx and nDFFx, we find similar outcomes between these groups in the first 30 days after surgery. Patients with pDFFx did have higher rates of surgical site complications, including infection and dehiscence. In pDFFx patients, those undergoing DFR were more likely to return home post-operatively., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Intramedullary (IM) nail use for metaphyseal fracture management is problematic in long bones like the femur because the larger medullary cavity allows increased fracture motion and potentially increased implant failure and malunion/nonunion risk; Achieving effective distal femur fracture fixation is even more difficult in osteoporotic bone. Blocking screws to control IM nail movement are known to be effective for tibia fracture management. Few studies have evaluated IM nail and blocking screw use efficacy for distal femur fracture fixation in osteoporotic bone., Methods: This study used an osteoporosis simulation synthetic bone model to evaluate retrograde IM nail fixation of a standardized non-comminuted, extra-articular distal femur fracture with and without blocking screws. The hypothesis was that use of one or two blocking screws would increase IM nail fixation stability as evidenced by greater peak IM nail load and lesser movement. A servohydraulic device under displacement control collected loading force versus movement deflection data. Shapiro-Wilk tests confirmed data normality. One-way analysis of variance and Tukey post hoc tests were used to compare condition specific loading force and movement differences., Result: In the coronal plane, blocking screw conditions displayed greater loading ranges (38.3 ± 2 vs. 19.1 ± 2 N, 100.5% difference) (p < 0.0001) and lesser movement (2.0 ± 0.3 vs. 6.86 ± 0.4 mm, 243% difference) (p < 0.0001). In the sagittal plane, the two blocking screw condition displayed a significantly greater loading magnitude (29.9 ± 6 vs. 20.8 ± 2.3 N, 43.8% difference) than the identical control condition without blocking screws (p = 0.018); however, movements were comparable (p = 0.82). Long-axis rotational loading failed to reveal load magnitude differences (p = 0.28); however, two different blocking screw conditions displayed decreased movement (1.32 ± 0.2 vs. 2.05 ± 0.3 mm, 53.8% difference) compared to other conditions (p ≤ 0.018)., Conclusions: Use of one or two blocking screws on the medial and lateral sides of the IM nail decreased coronal plane movement in the intramedullary canal. Combining retrograde IM nail implantation with blocking screws reduced medial-lateral IM nail movement and increased fracture stability. These characteristics may help prevent fixation failure, malunion, and even nonunion in patients with a distal femur fracture in osteoporotic bone., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: The incidence of periprosthetic femur fractures is increasing. Multiple treatment methods exist to treat fractures surrounding stable hip arthroplasty implants including locking plate fixation, cable fixation, allograft augmentation, and revision arthroplasty. No consensus regarding optimal treatment has been reached, and significant complications remain. Recently, biomechanical studies have demonstrated the benefits of orthogonal dual-plate fixation, but little clinical data exist. The purpose of the current study was to investigate the clinical and radiographic outcomes of dual-plated periprosthetic femur fractures around stable hip stems., Materials and Methods: Patients with periprosthetic femur fractures following hip arthroplasty with a stable femoral stem treated with dual-plate fixation were identified through chart review at a single institution. Fracture classification, fixation characteristics, radiographic outcomes, clinical outcomes and complications including re-operation were recorded., Results: Over a 12-year period, 31 patients (mean age 77 years at surgery, range 48-94) underwent dual plating by three traumatologists for implant-stable periprosthetic femur fractures surrounding a hip arthroplasty stem. There were 27 Vancouver B1-type and 9 inter-prosthetic fractures. Average follow-up was 2 years. Of the 26 patients with minimum 6-month follow-up, 24 (92%) united after index surgery (mean time to union 6.0 months, range 1.5-14.0). Mean time to full weight-bearing post-operatively was 2.6 months (range 1.5-4.0 months). Two patients required secondary surgery to address nonunion., Conclusions: Dual-plating achieved high union rates with an acceptable complication profile for the treatment of periprosthetic femur fractures surrounding a stable hip arthroplasty stem. Our preferred fixation construct involves a lateral plate spanning the entire femur secured with non-locking bicortical screws supplemented with an anteriorly based reconstruction plate. Additional prospective research is required to confirm the results of this study., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Periprosthetic femoral fractures are an increasingly common post-operative complication of total hip arthroplasty (THA). Though varus malalignment is known to increase fracture risk in standard-length femoral stems, varus malalignment is not as well studied in short stems. Therefore, the purpose of this study was to determine if varus malalignment contributes to early periprosthetic fracture risk in a cementless taper-wedged, short femoral stem., Materials and Methods: This retrospective review included 366 consecutive patients (441 THAs) having undergone THA via anterior approach by a single surgeon between July 2014 and December 2016. All patients received the same short, cementless femoral stem. Femoral component angle was measured on 6-week post-THA weight-bearing radiographs, with malalignment defined as a femoral component angle exceeding 0° ± 3°. Periprosthetic femoral fracture and aseptic loosening occurring within 2 years post-THA were recorded., Results: The final data analysis included 426 hips with a mean follow-up time of 32.9 ± 10.2 months. Varus and neutral alignment occurred in 84 (19.6%) and 342 (79.9%) of stems, respectively. Three (0.7%) periprosthetic femoral fractures occurred within 2 years, all occurring in patients with neutrally aligned femoral stems. One (0.2%) stem failed due to aseptic loosening and was malaligned., Conclusion: Despite nearly 20% of stems placed in varus alignment, three of the four early complications occurred in a neutrally aligned stem. Based on these results, forceful intraoperative realignment of a short femoral stem with good initial fixation may present an unnecessary increased risk of intraoperative fracture., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: This study aimed to evaluate the outcomes of dual plating for unstable distal femoral fractures via a subgroup analysis between periprosthetic and non-periprosthetic fractures., Methods: This retrospective cohort study analyzed the outcomes of dual plating for unstable distal femoral fractures among 49 consecutive patients (43 women and 6 men) enrolled from July 2008 to August 2020. The patients were divided into periprosthetic (group P, n = 29) and non-periprosthetic (group N, n = 20) groups. The radiographic outcomes included the mechanical lateral distal femoral angle (mLDFA) and union rate based on the computed tomography findings. The clinical parameters included the knee range of motion and knee society score (KSS)., Results: The mean patient age was 71.1 years, and the average follow-up period was 37 months (range, 12-138 months). Union was achieved in 47 patients (96%). The average final mLDFA was 90.5° in group P and 88.3° in group N. The average final knee range of motion was 130° in group P and 107° in group N. The average final KSS was 73.8 in group P and 87.1 in group N., Conclusion: Dual plating for distal femoral fractures yielded an excellent union rate and limb alignment with a low complication rate., (© 2022. The Author(s) under exclusive licence to SICOT aisbl.)

Introduction: The course of road traffic collision (RTC) victims with femoral fractures (FFx) from injury to death was reviewed. We sought to correlate the presence of femoral fractures with the overall severity of injury from RTCs using objective indices and to identify statistically significant associations with injuries in other organs., Patients and Methods: A case-control study based on forensic material from 4895 consecutive RTC-induced fatalities, between 1996 and 2005. Injuries were coded according to the Abbreviated Injury Scale-1990 Revision (AIS-90), and the Injury Severity Score (ISS) was calculated. Victims were divided according to the presence of femoral fractures in all possible anatomic locations or not. Univariate comparisons and logistic regression analysis for probabilities of association as odds ratios (OR) were performed., Results: The FFx group comprised 788 (16.1%) victims. The remaining 4107 victims constituted the controls. The FFx group demonstrated higher ISS (median 48 vs 36, p < 0.001) and shorter post-injury survival times (median 60 vs 85 min, p < 0.001). Presence of bilateral fractures (15.5%) potentiated this effect (median ISS 50 vs 43, p = 0.006; median survival time 40 vs 65, p = 0.0025; compared to unilateral fractures). Statistically significant associations of FFx were identified with AIS2-5 thoracic trauma (OR 1.43), AIS2-5 abdominal visceral injuries (OR 1.89), AIS1-3 skeletal injuries of the upper (OR 2.7) and lower limbs (OR 3.99) and AIS2-5 of the pelvis (OR 2.75) (p < 0.001). In the FFx group, 218 (27.7%) victims survived past the emergency department and 116 (53.2%) underwent at least one surgical procedure. Complications occurred in 45.4% of hospitalized victims, the most common being pneumonia (34.8%)., Conclusion: This study has documented that femoral fractures are associated with increased severity of injury, shorter survival times and higher incidence of associated thoracic, abdominal and skeletal extremity injuries, compared to controls. These findings should be considered for an evidence-based upgrading of trauma care., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purposes: Femoral implant related fractures (IRF) are a growing pathology in an increasingly elderly and frail population. A series of IRF after cephalomedullary nail (CMN) fixation of a femoral fracture is analyzed and an algorithm described to guide the management of such fractures., Methods: All eligible patients operated on for IRF fixation after CMN were reviewed regarding their demographics, comorbidities, injury pattern, and treatment. Primary outcomes were mortality and local complications. Secondary outcomes were time to consolidation, time to weight-bearing initiation, length of hospitalization, and discharge destination., Results: The incidence of IRF requiring fixation was 1.3% after 3401 CMN implantation procedures. Elderly women with comorbidities and plate fixation predominated. One-year mortality was 18.6%, being higher for patients presenting with infection and those unable to walk at the end of follow-up. Local complications occurred in 25.6%. Median time to weight-bearing was 9.1 weeks, but longer for patients with plate fixation or complications. Patients presenting with an infection and those discharged to nursing facilities had more comorbidity., Conclusions: Following an algorithm presented here, patients were treated either with nail exchange or lateral locking plate fixation, permitting straightforward evaluations and acceptable results in a very high-risk population., (© 2022. The Author(s) under exclusive licence to SICOT aisbl.)

Introduction: The importance of fixation construct in locking compression plate (LCP) is not well enlightened until recently. The aim of this study was to investigate radiological and clinical outcomes of scattering and clustering of the proximal screw fixation construct in unilateral LCP treatment of the distal femoral fractures., Materials and Methods: Patients who were treated for distal femoral fractures using unilateral LCP between January 2014 and December 2019 in our institute were included in this retrospective study. They were divided into groups 1 (35 cases, scattered proximal screw fixation) and 2 (35 cases, clustered proximal screw fixation). Mean follow-up period was 23.6 months for group 1 and 21.3 months for group 2. Medical history, patient demographics, injury characteristics, and surgical characteristics were reviewed and analyzed. Radiological findings including time to callus formation, bridging callus formation, union, and symmetry of the union were assessed and compared between the groups. Clinical outcomes included total blood loss during the operation, postoperative range of motion, and number of revision surgery., Results: The time for callus formation (5.8 weeks in group 1 vs. 4.1 weeks in group 2, p = 0.009) and bridging callus formation (12.5 weeks in group 1 vs. 10.7 weeks in group 2, p = 0.009) was significantly earlier in group 2. Despite similar union rates between groups, the mean time for radiological union was longer in group 2 (10.7 vs 7.4 months, p = 0.001). Though statistically insignificant, more asymmetric union was observed in group 2 (17 vs 11 cases)., Conclusions: Despite a delay in initial callus and bridging callus formation, scattering the proximal screws was better in achieving earlier and more balanced radiographic union than the clustered fixation. We recommend to avoid bridging more than five holes in the whole plate fixation construct to lessen the asymmetric callus formation and to prevent eventual plate breakage., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Functional results after internal fixation of trochanteric femoral fractures may be negatively affected by healing in a non-physiological position. The aim of this study was to evaluate the occurrence and severity of femoral malrotation after nailing of trochanteric fractures., Materials and Methods: The authors conducted a prospective study focused on a CT analysis of malrotation after intramedullary nailing of trochanteric fractures (AO 31A1-3) in 101 patients. We recorded the type of fracture, method of anesthesia, scheduled surgery vs. acute surgery, and the surgeon's experience as possible risk factors for limb malrotation after trochanteric fracture surgeries., Results: The average extent of malrotation was 9° of internal rotation ranging from 29° of external to 48°of internal rotation. In 35% of patients, we observed a rotation greater than 15°, and in 15 patients (15%), the rotation was greater than 25°. The risk of significant internal malrotation was significantly higher than external malrotation (37 vs. 4 patients). None of the factors observed proved to be statistically significant. The effect of general anesthesia and the type of intertrochanteric fracture came closest to having a significant effect on rotational error., Conclusion: Improper reduction of a trochanteric fracture is a common problem that can lead to femur malrotation. In our study, a rotational error greater than 15° occurred in 35% of the patients, but none of the monitored factors represented a statistically significant risk for this complication., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Sub-capital femoral fractures (SCFF) are impacted or non-displaced in Garden types 1 and 2, respectively. Non-surgical treatment is protected weight-bearing combined with physiotherapy and radiographic follow-up in selected patients. Traditionally, in situ pinning is the surgical treatment of choice. The aim of this study was to estimate whether the valgus deformity in Garden types 1 and 2 (AO classification 31B1.1 and 31B1.2) SCFF is a virtual perception of a posterior tilt deformity and if addressing this deformity improves patients' outcomes., Materials and Methods: The records of 96 patients with Garden Types 1 and 2 SCFF treated in tertiary medical center between 1/2014 and 9/2017 were retrospectively reviewed. They all had preoperative hip joint anteroposterior and lateral radiographic views. 75 patients had additional computed tomography (CT) scans. Femoral head displacement was measured on an anteroposterior and axial radiograph projections and were performed before and after surgery. Preoperative 3D reconstructions were performed for a better fracture characterization, and assessment of the imaging was performed by the first author., Results: The average age of the study cohort was 73 years (range 28-96, 68% females). There were 58 right-sided and 38 left-sided fractures. Ninety patients had Type 1 and six patients had Type 2 fractures. The average preoperative posterior tilt was 15 degrees and the average valgus displacement was 10 degrees on plain radiographs compared to 28 degrees and 11 degrees, respectively, on CT scans. Posterior tilt was found with a virtual perception as valgus-impacted fractures. The postoperative posterior tilt was corrected to an average of 3 degrees and the valgus displacement to 5 degrees., Conclusion: CT provides an accurate modality for measuring femoral head displacement and fracture extent. The posterior tilt displacement should be addressed during surgery to lower failure risk and the need for additional procedures., Irb Approval: TLV-0292-15., Level of Evidence: IV., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Periprosthetic femoral fractures (PFF) are detrimental for patients. Vancouver B2 fractures about a cemented stem can be revised to a longer uncemented stem or using an in-cement revision, if the cement mantle is adequate. There are reports documenting the success of both techniques. The aim of this single centre study was to perform a direct comparison of these two procedures., Materials and Methods: A retrospective study of consecutive Vancouver B2 PFFs around a cemented stem during 16 years was performed. All study cases were treated either using an in-cement revision or with an uncemented stem revision. Preoperatively, the groups were compared based upon age, gender, ASA, BMI, and Charlson comorbidity score. The outcome measures were surgical time, complications, in-hospital stay, revisions, 1-year readmission rate, and survivorship., Results: After a median of 3.5 years, there were 70 patients in the uncemented and 31 in the in-cement group. There was no difference in any of the preoperative variables. Surgical time was shorter for in-cement revisions by a mean of 45 min (p < 0.001). There was no difference in in-hospital stay, surgical complications or readmissions. Implant survival at 5 years was 93.5% for the in-cement and 94.4% for the uncemented revision (p = 0.946). Patient survivorship at 5 years was 62.5% for the in-cement and 69.8% for the uncemented group (p = 0.094)., Conclusions: This study demonstrates that in-cement revision is a valid treatment option for Vancouver B2 fractures, comparable to uncemented stem revision, if certain criteria are met. There was no difference in revision rate, patient survivorship, complications, readmissions or in-hospital stay., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

Background: The optimal treatment strategy for the surgical management of femur fractures and non-unions remains unknown. The aim of this study is to assess union rates, complications and outcome after femoral double plating. Treatment of shaft, distal, periprosthetic fractures and pathological proximal femur fractures as well as femoral non-unions with double plating were evaluated., Methods: A systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was conducted. Published literature reporting on the treatment and clinical outcome of femoral fractures and non-unions with double plating was identified. In total, 24 studies with 436 cases of double plating, 64 cases of single plating, 84 cases of intramedullary nailing (IM), and 1 interfragmentary screw treatment met the inclusion criteria of this systematic review. The evaluated literature was published between 1991 and 2020., Results: Double plating of femoral fractures achieved high healing rates and few complications were reported. It displayed significantly less intraoperative haemorrhage, shorter surgery time reduced risk of malunion in polytraumatised patients when compared to IM. Fracture healing rate of double-plating distal femoral fractures was 88.0%. However, there were no significant differences regarding fracture healing, complication or functional outcome when compared to single plating. Treatment of periprosthetic fractures with double plating displayed high healing rates (88.5%). Double plating of non-unions achieved excellent osseous union rates (98.5%)., Conclusions: The literature provides evidence for superior outcomes when using double plating in distal femoral fractures, periprosthetic fractures and femoral non-unions. Some evidence suggests that the use of double plating of femoral fractures in polytraumatised patients may be beneficial over other types of fracture fixation., Level of Evidence: IV., (© 2021. The Author(s).)

Background: Reverse oblique intertrochanteric fractures are classified by the AO/OTA as 31A3 and account for 2-23% of all trochanteric fractures. The Gamma 3-Proximal Femoral Nail (GPFN) and the Expendable Proximal Femoral Nail (EPFN) are among the various devises used to treat this fracture. The aim of this study was to compare outcomes and complication rates in patients with AO/OTA 31A1-3 fractures, treated by either a GPFN or an EPFN., Patients and Methods: A total of 67 patients (40 in the GPFN group and 27 in the EPFN group, average age 78.8 years) were treated in our institution between July 2008 and February 2016. Data on postoperative radiological variables, including peg location and tip-apex distance (TAD), as well as orthopedic complications, such as union rate, surgical wound infection and cut-outs rates were also recorded, along with the incidence of non-orthopedic complications and more surgical data. Functional results were evaluated and quantified using the Modified Harris Hip Score (MHHS) and by the Short Form 12 Mental Health Composite questionnaire (SF-12 MHC) in order to assess the quality of life., Results: The total prevalence of postoperative orthopedic complications including postoperative infection showed a significant difference with a p-value of 0.016 in favor of the EPFN group. Nonetheless, the frequency of revision did not differ between the two groups, being 0.134. The main orthopedic complication in both groups was head cut-out of the GPFN lag screw and the EPFN expendable peg, which was 20% and 7.4%, respectively, and required a revision surgery using a long nail or total hip replacement (THR). However, the average TAD did not significantly differ between groups which might be due to a relatively low cohort to reach a significant difference. Nonunion rate of 5% occurred solely in the GPFN group, with similar results of intraoperative open reduction between both groups. The EPFN group achieved better scores in both questionnaires (p = 0.027 and p = 0.046, respectively). Both the MHHS and SF-12 MCS values significantly differed between groups, with the EPFN group achieving better scores than the GPFN group in both questionnaires (p = 0.027 and p < 0.05, respectively)., Conclusions: According to this study, the EPFN yields better results in comparison with the GPFN, with relatively less complications rate, for the treatment of unstable reverse oblique pertrochanteric fracture. In light of this results, we conclude that the EPFN might be as good as GPFN for the treatment of reverse oblique intertrochanteric fractures., Level of Evidence: Level III retrospective study. The local institutional review board of the Tel Aviv Medical Center approved this study and all the surgeries were done exclusively in this institution., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

Aim of the Study: This was to compare the early outcome of closed femoral shaft fractures treated with locked intramedullary nailing and plating at the National Orthopaedic Hospital Enugu., Methods: The study was a prospective study over 12-month period at the National Orthopaedic Hospital Enugu. Ethical clearance was obtained from the hospital ethical committee. Written informed consent was obtained from all prospectively recruited participants. Patients who met the inclusion criteria were randomly selected by simple balloting into either intramedullary nailing group or plating group. The patients were evaluated at presentation and postoperatively within 48 hours, then at two weeks, six weeks, 12 weeks and 18 weeks, respectively. Participants were evaluated using Thoresen criteria., Results: A total of 52 femoral shaft fractures in 50 patients were included and analysed using SPSS version 20.0. Bone union was obtained in all the patients in the intramedullary nailing group at 12 weeks and in 84.6% patients in the plating group between 12 and 18 weeks. The overall wound infection rate was 11.5% in the locked intramedullary group and 7.7% in the plating group. Similarly, the overall limb length discrepancy was 11.5% in the locked intramedullary nailing group and 19.2% in the plating group. Based on the Thoresen criteria, good to excellent outcome was achieved in 65.4% of patients in the locked intramedullary nailing group., Discussion: The patients in both groups were evaluated clinically, radiologically and functionally based on the Thoresen criteria and significantly higher number of patients in the intramedullary nailing group (17; 65.4%) than the plating group had good to excellent outcome (x 2  = 9.734; p = 0.020)., Conclusion: The early outcome of treatment of closed femoral shaft fractures in adults is significantly better following locked intramedullary nailing than plating., (© 2020. SICOT aisbl.)

Introduction: Post-radiation fractures of the femur (PRF) are difficult to treat and are associated with a high risk of delayed union and non-union. We report a series of patients affected by soft tissue sarcoma (STS) of the thigh, treated with limb-sparing surgery and perioperative radiotherapy (RT), to analyse post-radiotherapy femur fracture (FF) rate and its management., Material and Methods: 547 patients treated with surgery and RT for a deep primary STS of the thigh were included. "Periosteal stripping" and "bone tangential resection" were performed in case of tumor invasion. In the case of complete bone involvement, the patient received its complete resection and econstruction., Results: Twenty-three (4.3%) patients underwent surgical procedures involving periosteum and cortical bone. In 11 (2.0%) patients a bone resection was required because of massive bone involvement. Six out of these 11 (54.5%) patients developed major complications (infection and aseptic loosening). At the time of STS excision, 11 patients (2.0%) underwent prophylactic intramedullary nailing (PIN). PRF occurred in 15 patients (3.0%) at a median follow up of 52 months (range 3-151). Among patients who developed PRF, three were treated with a prosthesis (no complications) and eight nailing (7/8, 87.5% did not heal and developed a non-union)., Conclusions: Given the potentially devastating complication of a PRF, PIN should be considered. We suggest prophylactic IM nail in patients at higher risk the time of STS excision. In other cases, IM nail can be postponed in the following years considering the prognosis., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Pathological femoral fracture (PFF) after radiation therapy (RT) for soft tissue tumor is a debilitating complication with a high rate of nonunion that requires multiple subsequent procedures and hindrance of functional activity. We aimed to evaluate healing rate after repeated internal fixation in a case series of PFF after RT., Materials and Methods: We retrospectively reviewed the records of patients who had PFF after RT and were treated at our center between 2007 and 2018. We analyzed our surgical protocols and fracture healing rate., Interpretation: We identified and analyzed a total of seven patients (six females and one male) whose mean age at fracture was 58 years. Primary tumors consisted of soft tissue sarcoma (n = 5), melanoma (n = 1), and desmoid tumor (n = 1). All primary tumors were treated with surgical excision and adjuvant RT. The mean follow-up duration after fracture was 33 months (range, 16-58). At the last follow-up, five out of seven fractures had completely healed, and two lesions showed delayed union at 15 and 16 months, respectively. Among the five complete unions, one fracture was healed after the first fixation. The remaining four lesions were treated with second internal fixation due to nonunion/metal failure or delayed union. The mean time to radiologic healing after the last fixation was 6.8 months (range, 5-8)., Conclusions: Our results suggest that bones within the RT field retain healing capacities, and that repeated internal fixation may be a viable option for the treatment of PFF after RT.

The incidence of periprosthetic fractures of the proximal femur is increasing due to the growing numbers of hip replacements in old age. The treatment of these fractures is a challenge for the treating physician and standardized procedures are necessary. The unified classification system (UCS) is a suitable tool to establish treatment strategies: On the basis of the fracture localization and extent, bone quality, stability of the prosthesis and the presence of further implants, the fractures can be classified according to the UCS and a treatment algorithm can be derived. This article gives an overview of the diagnostics, classification and characteristics of the various periprosthetic fracture types as well as the treatment.

Introduction: Hip arthroplasty (HA) is commonly performed to treat various hip pathologies. Its volume is expected to rise further due to the increasing age of the population. Complication rates are low; however, periprosthetic femoral fractures (PFF) are a rare, albeit serious, complication with substantial economic impact. While current guidelines propose revision with long-stemmed prostheses for all Vancouver B2 and B3 PFF, some recent research papers suggest that open reduction with internal fixation (ORIF) could lead to an equivalent outcome. Our aim was to summarize the evidence, elucidating under which circumstances ORIF leads to a favorable outcome after B2 and B3 PFF compared with revision surgery., Materials and Methods: A systematic literature search was performed to identify studies on patients treated with ORIF and with stem revision after B2 and/or B3 fractures. Extracted information included initial pathology, stem fixation mechanism, bone quality and stem stability at the time of PFF, clinical outcomes, and mortality. Results of individual studies were summarized in a table in lieu of a quantitative data synthesis due to a lack of standardized information., Results: We identified 14 original research articles including both patients treated with ORIF and with stem revision after B2 and/or B3 PFF. Five studies included statistical comparisons, all were in favor of ORIF or indeterminate. The common lack of rigorous statistical analyses and significant methodological weaknesses made identification of outcome predictors impossible., Conclusion: The choice of treatment modality for PFF depends on fracture, implant, and bone characteristics. Recent data show that successful outcome can be achieved without revising loose stems. ORIF may be a viable option if bone stock is adequate around uncemented or tapered polished stems with an intact cement mantle and the fracture geometry allows stable anatomic reconstruction. Conceptional considerations support this idea, but more data are needed to identify outcome predictors.

Introduction: Neglected epiphyseal fracture-separations of the distal femur are rare. Still reported in developing countries, they lead to therapeutic issues. The objective of the study is to describe their characteristics and to propose treatment options., Materials and Methods: Ten years of ongoing study was held in our orthopedics department. All patients with a neglected epiphyseal fracture-separations of the distal femur after a knee trauma were included in the study. Pre-operative and post-operative data were collected and analyzed., Results: A total of 13 cases of neglected traumatic epiphyseal fracture-separations of the distal femur were found among 8616 in-patients of the department. It was mainly boys (9M/4F) around 16 years that were received 14 weeks after knee trauma. Most of the injuries were an AO-type 33-E/2.1 (Simple Salter-Harris' type II) (n=12) distal femur malunion (n=10). Associated complications were cutaneous opening (n=7), superficial infection (n=4), deep infection (n=4). Fractures were management surgically (n=12) by an open osteoclasis procedure (n=9), debridement (n=7) and a thigh amputation (n=1). The outcome was better if an open osteoclasis procedure was early performed in closed distal femur mal-union with a complementary rehabilitation program., Conclusion: Specialized trauma care facilities must be increased, and trauma education programs must be undertaken to avoid neglected epiphyseal fracture-separations of the distal femur in developing countries.

Background: The number of total hip arthroplasties (THA) is expected to increase worldwide; thus, complications are likely to increase at the same ratio. In this scenario, periprosthetic femoral fractures (PFFs) are an increasing concern. Identifying the predisposing factors is important in order to prevent as much as possible the risk of PFF in the future., Patients and Methods: The purpose of this study was to correlate the risk of periprosthetic femoral fractures to the most common patients' comorbidities and stem geometry. We reviewed all THA for non-oncologic indications between 2004 and 2014 with a mean follow-up of six years (range, 2-12). Three thousand two hundred forty-eight patients (3593 implants) were enrolled in the study, and 45 PFF were registered during this time period. Two thousand five hundred seventy-seven implants (71%) were straight stems, and 1015 (28.3%) were anatomic stems. All X-rays were then analyzed and classified according to the modified Vancouver classification., Results: Periprosthetic femoral fractures incidence was associated with anatomic stem geometry (p < 0.001, OR = 2.2), BMI (p < 0.001), and diabetes (p < 0.001, OR = 5.18). PFFs were not significantly associated with age, gender, and all the other variables. Fracture pattern was different between straight and anatomic stems. Clamshell fractures were more likely to occur in anatomic stems compared to straight stems (p < 0.005)., Conclusions: Periprosthetic femoral fractures are highly associated with obesity and osteoporosis. Anatomic stems reported a higher incidence of PPF than straight stems. The typical fracture type for anatomical stems is the clamshell pattern, while straight stems are more likely affected by type B fractures.

Purpose: What are the overall, 30-day, 6-month, and 1-year mortality rates following distal femur fractures?, Methods: Epidemiological cohort study. Retrospective reviews of charts and X-rays based on a search in the National Danish Health Registry., Results: A total of 293 patients were treated for 302 distal femur fractures between 2005 and 2010. The mean age at the time of fracture was 44.0 years for males and 71.6 years for females. The overall mortality rates after a non-periprosthetic distal femur fracture at 30 days, six months, and one year were 5%, 15%, and 21%, respectively. The mortality rates for patients at > 60 years at 30 days, six months, and one year were 8%, 26%, and 35%, respectively. The mortality rates for patients at ≤ 60 years at 30 days, six months, and one year were 1%, 2%, and 3%, respectively. The overall mortality rates after a periprosthetic distal femur fracture at 30 days, six months, and one year were 10%, 15%, and 15%. Males were 2.6 (95% CI 1.01-6.86, P = 0.04) times more likely to die within the first year compared to women. Patients treated by conservative means shows a 2.8 (95% CI 1.41-5.54, P = 0.03) times increased likelihood of death within the first year compared to patients treated with surgery., Conclusions: The overall one year mortality rate was 21% for non-periprosthetic distal femur fractures and was elevated to 35% in patients older than 60 years. Patients presenting with a periprosthetic fracture showed a one year mortality rate of 15%.

Background: Cementless hemiarthroplasty is a widely used treatment for femoral neck fractures. Intra-operative femoral fracture occasionally occurs during the procedure, and the use of cerclage wire has been proposed to stabilize both the prosthesis and the bone. This study aimed to investigate the outcomes of cerclage wiring to manage intra-operative fractures occurring during cementless hemiarthroplasty in older patients with a femoral neck fracture., Methods: Medical records and radiographs of older patients with femoral neck fractures who underwent hemiarthroplasty during 2009 to 2015 were retrospectively reviewed. Patients who received cerclage wiring were matched with a demographically matched control group that did not. Patients were followed for at least 12 months. Functional outcomes and health-related quality of life were evaluated by determining the distance of distal stem migration, Barthel Index, EuroQol-visual analog scale (VAS), and pain-VAS., Results: Eighty-one patients were included, comprising 27 study group and 54 control group patients. A tapered wedge-shaped femoral prosthesis was implanted in all cases. No significant differences in distance of distal stem migration or rate of stem subsidence > 2 mm were observed between the case and control groups (subsidence rate 11.1 vs. 14.8%, respectively). There was also no significant difference in functional outcomes between groups., Conclusion: Our results revealed a low mean distance of distal stem migration and a low subsidence rate. Functional outcomes and quality of life were similar between the two groups. Cerclage wiring technique is safe, and it should be routinely performed when intra-operative femoral fracture occurs during cementless hemiarthroplasty.

The incidence of periprosthetic hip fractures is increasing due to the increase in endoprosthetic hip replacements. These fractures require a staged and individual treatment concept with the aim of mobilization of the patient as early as possible. The special challenge in the diagnostics is to identify pre-existing signs of loosening of the prosthesis. When the prosthesis is still firmly fixed femoral fractures can be treated with angular stable osteosynthesis. Loosened stems usually have to be revised, mostly in combination with osteosynthesis. Fractures around the acetabulum with a fixed cup can be treated nonoperatively or with osteosynthesis, while loosened cups have to be revised. In revision surgery the stabilization of the dorsal column is crucial for a successful outcome.

Background and Purpose: As patients who were afflicted with poliomyelitis during the outbreaks in the past are aging, lower extremity osteoporotic fractures are becoming more frequent. Fixation in deformed, porotic bone, coupled with muscle weakness and imbalance creates a unique challenge when treating these fractures as does their reduced rehabilitation potential. The aim of this study was to investigate the outcome of femoral fractures in surviving poliomyelitis patients., Patients and Methods: Sixty-five patients with 74 femoral fractures were treated between 1990 and 2014. Clinical outcome was assessed using the Parkland and Palmer mobility score, and quality-of-life was assessed using the SF-12® score., Results: Some 84% of the fractures were a result of low-energy mechanisms and occurred in the polio-affected limbs, but nonaffected limbs were also injured owing to low-energy mechanisms in all cases. Fifty-seven fractures were treated operatively. There were nine re-operations (16%), including implant removals, nonunion, peri-implant fractures, and malunion. Some 60% of the patients did not regain their previous ambulatory capacity. Post-operative weight-bearing status did not correlate with the final functional outcome., Conclusions: Polio patients with femoral fractures have a guarded prognosis for regaining their pre-injury ambulatory capacity. A higher re-operation rate than that with "normal" osteoporotic fractures is expected.

Although Asian with bisphosphonate has been considered to have higher risk of subtrochanteric and diaphyseal femur (ST/DF) fractures, the occurrence of those fractures has been still unclear in Asia. The purpose of this study was to investigate the incidence rate of ST/DF fractures among bisphosphonate users from nationwide database in South Korea. Using national health insurance claim database, we only included the bisphosphonate users who took bisphosphonate for the first time in 2008 and evaluated the incidence rate of ST/DF fracture from 2008 to 2013. Non-user controls were matched to bisphosphonate users by propensity score matching with age and gender. Cox regression models were used to calculate hazard ratios of ST/DF fracture with and without adjustment for comorbidity. A total of 682 ST/DF fractures were observed among 348,311 bisphosphonate users. The incidence rate of ST/DF fracture among bisphosphonate users (37.75/100,000 person years, 95% CI 35.02-40.70) was higher compared with non-users (24.41/100,000 person years, 95% CI 22.31-26.71). The risk of ST/DF fracture was greater in bisphosphonate users compared with non-users (hazard ratio 1.541, 1.370-1.734; p < 0.001). The incidence rate of ST/DF fracture after bisphosphonate use could be determined in Korean patients, which can provide basal information for further studies on risk and benefit of continuing bisphosphonate.

Aims: This study was performed to evaluate the efficacy of reconstructing bone stock in Vancouver B3 periprosthetic femoral fractures (PFFs) using an impacted cancellous allograft cortical or combined with cortical strut allograft., Patients and Methods: We retrospectively assessed 39 Vancouver-type B3 periprosthetic fractures in 39 patients. Having different bone defects in the femur, 20 patients were treated with intramedullary impacted cancellous allograft, and 19 patients were treated with impacted cancellous allograft combined with cortical strut allograft. The median follow-up time was 58 months., Results: Thirty-three patients completed the follow-up as scheduled, and three of them underwent re-operation (9.1%, 3/33). The last evaluated mean hip Harris score was 81.8; WOMAC pain, stiffness, and function scores were 82.3, 79.0, and 81.3, respectively. The satisfaction score was 86.6, and the SF-12 mental and physical scores were 40.4 and 51.1, respectively, for all patients. These outcomes were without significant difference between the two treatment groups (p > 0.05). The facture union was achieved in all the hips (100%). The stem was fixed with bone ingrowth in 24 patients and with fibrous fixation in eight, while stem fixation was not achieved for the remaining patient. The stem subsided less than 3 mm in 23 patients and 3-5 mm in nine patients. One patient had > 5 mm subsidence. The femoral bone stock was improved in 18 patients and remained unchanged in 14 patients; only one patient suffered a diminished bone stock. The radiographic assessment outcomes exhibited little difference between the two treatment groups (p > 0.05). Osseous union of the cortical strut to the host femur occurred in six patients with partial union and ten with complete union. There was moderate and mild graft resorption in three and 13 hips, respectively., Conclusions: The use of impacted cancellous allograft and cortical strut allograft to reconstruct bone stock can provide reliable options and satisfactory results.

This article presents the case of an 83-year-old woman with a peri-implant femoral fracture after hip arthrodesis in adolescence. Due to the rarity of such operations, there is no standardized approach for these cases. In order to secure the treatment goal of rapid pain-adapted full weight bearing despite reduced bone quality, it was decided to perform a new osteosynthesis with a retrograde femoral nail after removal of some fixation screws of the existing arthrodesis plate. Due to this type of treatment, the preservation of activity and independence of an older trauma patient could be sustainably secured despite operative challenges. Taking an extended osteoporosis treatment into consideration, a bony fracture consolidation and complete convalescence of activity and autonomy were ultimately achieved.

Background: The objective of this study was to analyze the prevalence and causes of early re-operation after hip replacement surgery using short bone-preserving stems in a large multicentre series. Specifically, we evaluated the clinical features of periprosthetic fractures occurring around short stems., Methods: A total of 897 patients (1089 hips) who underwent primary total hip arthroplasty or bipolar hemiarthroplasty from January 2011 to February 2015 using short bone-preserving femoral stems were recruited. Mean patient age was 57.4 years (range, 18-97 years), with a male ratio of 49.7% (541/1089). Re-operation for any reason within two years was used as an endpoint. The incidence and clinical characteristics of the periprosthetic femoral fractures were also recorded. Mean follow-up period was 5.1 years (range, 2-7.9 years)., Results: Early re-operation for any reason was identified in 16 (1.5%) of 1089 hips. The main reason for re-operation was periprosthetic femoral fracture, which accounted for eight (50%) of the 16 re-operations. The overall incidence of periprosthetic femoral fracture at two years was 1.1% (12/1089). According to the Vancouver classification, two fractures were AG type and the other ten were B1 type. Advanced age, higher American Society of Anesthesiologist grade, femur morphology of Dorr type C, and the use of a calcar-loading stem increased the risk for periprosthetic femoral fracture., Conclusion: Periprosthetic femoral fracture was the major reason for re-operation after hip replacement surgery using short bone-preserving stems accounting for 50% (8/16) of re-operations two years post-operatively, but did not seem to deteriorate survivorship of implanted prostheses.

Introduction: We aim to review the incidence and risk factors for the development of intraoperative periprosthetic femur fractures while performing a bipolar hemiarthroplasty for displaced neck of femur fractures. Our secondary aim is to characterize the types of intraoperative periprosthetic fractures, the steps leading to the fractures, and the salvage treatments instituted., Materials and Methods: 271 patients treated with bipolar hemiarthroplasty after traumatic displaced femoral neck fractures were retrospectively analyzed. Demographic data, co-morbidities, vitamin D level, consumption of steroids, ASA score, surgical approach, surgeon experience, use of cemented or uncemented implants, proximal femur morphology, and types of anaesthesia were analyzed statistically., Results: There were 28 patients (10.3%) with intraoperative periprosthetic femur fractures. We found two significant independent risk factors which were the use of uncemented prosthesis (OR 4.15; 95% CI 1.65-10.46; p = 0.003) and Dorr type C proximal femurs (Dorr A OR 3.6; 95% CI 1.47-8.82; p = 0.005). In addition, patients with Dorr type C proximal femurs who underwent uncemented bipolar hemiarthroplasty were more likely to sustain an intraoperative periprosthetic fracture (14(73.7%) out of 19 patients; p = 0.002). There were no significant differences found in other risk factors. The most common location for these fractures was at the greater trochanter at 11 (39.3%) cases. Majority of them, 15 (53.6%), had intraoperative fractures during trial implant insertion and reduction., Conclusion: The overall incidence of intraoperative periprosthetic femur fractures during hemiarthroplasty for displaced neck of femur fractures was 10.3%. The incidence was significantly higher for uncemented (14.7%) when compared to cemented prosthesis (5.4%) and the greater trochanter was the commonest area for periprosthetic fractures during trial implant insertion and reduction. Uncemented prosthesis and Dorr type C proximal femurs were two significant independent risk factors contributing to intraoperative periprosthetic fractures. By identifying these risk factors, surgeons can take ample precautions to prevent complications.

Purpose: The literature lacks recent epidemiological studies on the incidence, trauma mechanism and fracture classification of distal femur fractures. The aim of the present study was to provide up-to-date information concerning the incidence of distal femur fractures in a large and complete population and to report on the distribution of fracture classification, trauma mechanisms and patient baseline demographics., Methods: The approach for this study was via a retrospective reviews of records., Results: A total of 293 patients were treated for 302 distal femur fractures between 2005 and 2010. The mean age at the time of fracture was 62.2 years. The mean age was 44.0 years for males and 71.6 years for females. The gender distribution was 33.4% males and 66.6% females. The overall incidence of distal femur fractures was 8.7/100,000/year. After the age of 60 years, a rapid increase in the incidence of distal femoral fractures was observed in both genders, with a large female predominance. Low-energy injuries were the most common mode of injury in both genders (97%), with approximately 61% being the result of a fall from standing height. AO classification type A (extra-articular fractures) was the most common of all fractures (38.6%). Eighty-four patients (28.7%) were admitted with periprosthetic fractures, corresponding to an overall incidence of periprosthetic fractures of 2.4/100,000/year., Conclusions: The present study shows an incidence of 8.7/100,000/year of distal femur fractures. After the age of 60 years, a rapid increase in the incidence of distal femoral fractures was observed in both genders, with a considerable female predominance.

Purpose: We treat periprosthetic fracture of the distal femur above total knee arthroplasty using single or double plating and the minimally invasive plate osteosynthesis (MIPO) technique. Here, we report the results of using this operative treatment and our analysis of whether very distally extended fractures can also be successfully treated using internal fixation., Methods: We retrospectively reviewed 32 periprosthetic distal femoral fractures. Mean patient age was 73 years and mean follow-up period 25 months. There were 11 (34.4 %) Su type I/II and 21 (65.6 %) type III fractures. All Su type I/II fractures were treated by single plating, whereas 14 of 21 (66.7 %) type III fractures were treated using double plating and the MIPO technique. We defined bony union as the primary endpoint of this study based on callus formation across the fracture site at two or more cortices (1 medial and 1 other) on 3D computed tomography (CT)., Results: Bony union was confirmed in 30 cases (93.8 %) after a mean time to union of 3.7 (range, 3-7) months. Two patients showed nonunion (6.2 %), and one demonstrated delayed union (3.1 %), none of whom complied with our rehabilitation protocol. There was one instance of nonunion among both Su types I/II and III fractures; however, this difference was not significant (p = 0.577)., Conclusions: Periprosthetic fractures of the distal femur can be successfully healed using internal fixation, either the single- or double-plate MIPO technique, even for very distally extended fractures.

Purpose: Stem loosening in both cemented and uncemented total hip arthroplasty is the hallmark of the Vancouver type B2 classification of periprosthetic hip fractures., Methods: We discuss the technique we use at our institution for treating these fractures., Results: Periprosthetic femoral-shaft fractures are associated with a relatively high mortality rate, approximating that of patients with hip fractures. Outcomes are directly associated with early mobilisation and construct stability., Conclusions: We recommend performing the procedure only when the surgeon is proficient in revision hip surgery and trauma care. A well-selected portfolio of different stem designs and an array of osteosynthesis devices should be available, as well.

Purpose: Periprosthetic femur fracture is a potentially worrisome phenomenon for cementless stem fixation. The aim of this study was to document the incidence of stem loosening following periprosthetic femur fracture in previously well-fixed cementless grit-blasted tapered-wedge stems., Methods: We identified 36 periprosthetic femur fractures of either Vancouver B1 or B2 following hip arthroplasties using cementless grit-blasted tapered-wedge titanium stems at three participating institutions (GB group). The control group consisted of 21 periprosthetic femur fractures of either Vancouver B1 or B2 following hip arthroplasties using cementless proximal porous-coated stems at the same institutions during the same period of study (PC group). All femoral stems had been in a well-fixed state before occurrence of fracture. All patients were treated surgically and femoral stem stability was assessed using preoperative radiographs and confirmed by intraoperative scrutinization., Results: Seven (19.4%) of 36 fractures were Vancouver B1 and 29 (80.6%) were Vancouver B2 in the GB group, whereas 18 (85.7%) of 21 fractures were Vancouver B1 and 3 (14.3%) were Vancouver B2 in the PC group (P < 0.0001). The odds ratio for stem loosening was 24.86 (95% CI, 5.69-108.63) in the GB group versus the PC group., Conclusions: Hip arthroplasty using cementless grit-blasted tapered-wedge titanium stems showed higher incidence of stem loosening in association with periprosthetic femur fracture than hip arthroplasty conducted using proximal porous-coated stems. A high index of suspicion of stem loosening might be necessary in periprosthetic femur fracture following hip arthroplasty using this type of stems.

Purpose: The number of patients having hip and knee arthroplasties on the ipsilateral leg is going to rise. In this regard, the prevalence of interprosthetic femoral fractures is going to increase further. The treatment of these fractures is difficult and sometimes it is impossible to perform an osteosynthesis because of worse bone quality. The goal of this study was to investigate the use of an interposition sleeve as an alternative treatment option for interprosthetic fractures with major bone loss., Methods: Six human cadaveric femurs were instrumented using cemented hip- and knee prosthesis. Interprosthetic fractures were induced during a four-point-bending test and then treated using the interposition sleeve. Afterwards the constructs were tested using the four-point-bending test again., Results: Load-to-failure of the construct before fracturing was significantly higher than after treatment with the interposition sleeve (10681 N vs. 5083 N; p = 0.002). The failure mechanism of the femurs with the interposition sleeve was plastic deformation of the hip or knee prosthesis. The interposition sleeve did not fail in any specimen., Conclusion: The interposition sleeve is a valuable treatment option for interprosthetic fractures in situations in which osteosynthesis is impossible or insecure due to major bone defects. However, fracture healing should be preferred whenever possible.

Purpose: The purpose of this study is to report on the cumulative incidence and the outcome of surgically-treated postoperative PPFs in patients with femoral neck fractures treated with a THA or HA using an Exeter stem., Methods: A consecutive series of patients operated during 1998-2010 due to a non-pathological femoral neck fracture using an Exeter stem were included in this cohort study. Patients were followed until 2012, or death, in order to obtain information about reoperations due to postoperative PPFs, and subsequent re-operations after surgery due to PPFs. In addition to local audit data the Swedish National Board of Health and Welfare's registry was used to identify patients who had been re-operated upon elsewhere in Sweden., Results: A total of 2,757 patients (median age 82 years, 2,019 females) were identified and included in the study. Of these patients, 63 (2.3%) sustained a postoperative PPF that was treated surgically. The majority of the Vancouver B1 (n = 21/23) and C (n = 14/14) fractures were treated using open reduction and internal fixation (ORIF), whereas most of the B2 (n = 16/25) fractures and the only B3 fracture were treated with stem revision. Three (4.8%) patients were subsequently re-operated upon due to fracture-related complications, all B2 fractures, and were treated with ORIF (n = 2) or stem revision (n = 1)., Conclusion: The cumulative incidence of surgically treated PPFs was considerable among patients with Exeter stems operated due to a femoral neck fracture. The re-operation rate due to fracture-related complications was highest among patients with B2 fractures.

Atypical femoral fractures have unique radiologic and clinical feature. Most commonly used fixation method for atypical femoral fracture is interlocking intramedullary (IM) nailing. The aim of this paper is to document a rare case of a 76-year-old female who sustained bilateral proximal femoral insufficiency fractures after conventional interlocking IM nailing for bilateral atypical femoral shaft fractures without taking history of bisphosphonates. We recommend the routine use of full-length reconstruction or cephalomedullary-type interlocking IM nail for atypical femoral fractures.

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.

Purpose: This study aimed to analyse functional outcome and quality of life (QoL) after surgical treatment of periprosthetic femoral fractures (PPF) following total hip arthroplasty (THA)., Methods: This retrospective study assessed 67 patients from 2005 to 2012. Epidemiologic data, surgical details, comorbidities, deaths and postoperative complications were recorded. Functional assessment included Harris Hip Score (HHS) and range of motion (ROM); QoL was assessed using the Short-Form Health Survey of 36 questions (SF-36) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores., Results: Mean HHS was 69 ± 21 and ROM 96° ± 17°. Mean SF-36 and WOMAC scores revealed 44 ± 7.2 and 18.9 ± 19.6, respectively. The complication rate was 25.4%; 23.7% of patients died. Analysis revealed no statistical influence on final outcome as a function of fracture type or treatment strategy. Comorbidities seem to influence functional outcome., Conclusion: PPF following THA are accompanied by a perceptible decline of function and remarkably high complication rates. In contrast to fracture classification and treatment type, American Society of Anesthesiologists (ASA) score predicts outcome.