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Background: The purpose of this study was to determine implant survivorship and functional outcomes for revision total knee arthroplasty (rTKA) with contemporary rotating-hinge knee implants., Methods: A retrospective review identified 115 rTKAs using contemporary rotating-hinge implants from 2014 to 2018 for the treatment of instability (34, 30%), reimplantation after periprosthetic joint infection (PJI) (33, 29%), aseptic loosening (25, 22%), arthrofibrosis (14, 12%), periprosthetic fracture (4, 3%), osteolysis (4, 3%), and femoral component fracture (1, 1%). There were 70 women (61%), and the mean age was 67 years (range, 27 to 94). The mean follow-up was 3 years (range, 2 to 6). Kaplan-Meier analysis and Cox proportional hazard models estimated survivorship., Results: The re-revision rate was 20% (23 of 115) at an average of 18 months postoperatively. Re-revision indications included PJI (n = 14), aseptic loosening (n = 4), arthrofibrosis (n = 2), instability/malalignment (n = 1), femoral stem fracture (n = 1), and hinge mechanism disruption (n = 1). At 2 and 5 years, survivorship free from all-cause re-revision was 86 and 64%, and survivorship free from re-revision for aseptic loosening was 100 and 87%, respectively. Use of a rotating-hinge implant in reimplantation after PJI was a risk factor for subsequent re-revision (hazard ratio = 2.4, P = 0.046). On a radiographic review of unrevised rotating-hinges, there were major radiolucent lines around 2 femoral and 5 tibial components. The mean Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement increased from 43 preoperatively to 60 at 1 year (P < 0.001)., Conclusions: In patients treated with a rotating-hinge implant for rTKA, there were relatively poor 2-year (86%) and 5-year (64%) survivorship free from all-cause re-revision, most commonly due to PJI. Midterm survivorship free from re-revision for aseptic loosening was modest (87%). There should be a goal to mitigate complications in complex rTKAs with rotating-hinge implants, namely PJI., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Objective: Post-operative periprosthetic femoral fractures (POPFF) present a growing challenge for healthcare services, but there are limited national data on patient profiles, short-term outcomes, and post-discharge follow-up. We aimed to fill these gaps., Methods: Using Hospital Episode Statistics (HES), we identified POPFF discharges from hospitals in England for patients aged 18 and above between April 2016 and December 2022. We flagged prior admissions for hip fracture and elective hip or knee replacement surgery (primary, revision or re-revision) between April 2000 and the day of the POPFF admission date. We extracted information on patient factors, treatment modes for POPFF (nonoperative, fixation, revision), and outcomes (in-hospital mortality, length of stay, unplanned readmission). We used outpatient data to summarise post-hospitalisation follow-up., Results: Of 39,035 cases, 65.9 % were female; the median age was 82 years. HES data identified that 34.0 % had previously undergone elective hip replacement, 26.2 % elective knee replacement, and 22.8 % surgery for hip fracture. Those with a prior hip fracture were more likely to have delirium during the index POPFF admission, and, compared with those with a prior elective hip or knee replacement, they faced higher in-hospital mortality (5.1 % vs 3.2 % and 3.6 %, respectively), rates of readmission (15.4 % vs 13.1 % and 12.8 %, respectively), and hip re-fracture after POPFF (2.9 % vs 1.2 % and 1.6 %, respectively). Their median length of stay was longer (16 vs 14 days, p < 0.001). The most common reason for hospital readmission following POPFF was another fracture (11.3 % of all readmissions). Overall, 74 % of patients were discharged from outpatient follow-up within 12 months., Conclusion: This is the first national description of the burden of adverse outcomes for people with POPFF in England, of whom a large proportion require ongoing specialist support. Fewer POPFF cases follow prior hip fracture surgery than elective joint replacement, but these patients face higher risks of worse outcomes. With an expected increasing incidence of POPFF, this may have considerable health service implications., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: A decade ago, a comprehensive study was conducted to investigate the reasons for revision surgeries and their respective frequencies in cases of total hip arthroplasty (THA) and total knee arthroplasty (TKA) based on a complication-based analysis of joint replacement registries. The aim of the present study was to determine whether the causes and risks of their occurrence have changed over the last ten years and to present an updated analysis., Materials and Methods: A systematic review of national arthroplasty registries from seven countries examined the causes and rates of revisions of THA and TKA. The study focused on a descriptive analysis that provided an updated overview without statistical significance values., Results: The most common causes for revisions of THA were aseptic loosening (35.1%), deep infection (18.2%), dislocation/instability (15.9%), and periprosthetic fractures (11.4%). The most common causes for revisions of TKA were deep infection (21.6%), aseptic loosening (18.3%), instability (14.1%), and pain (10.9%)., Conclusion: The findings of this study revealed significant shifts in the underlying causes of revision surgeries in the last decade. Notably, septic complications emerged as the predominant reason for revision of primary TKA, while they also gained prominence as a cause of failure of THA. Although aseptic loosening remains the primary cause for re-operation of THA, the relative risk has decreased for both THA and TKA., Competing Interests: Declarations. Conflict of interest: Author A.L and P.S have received institutional grants from Medtronic, Alphamed, Johnson & Johnson not directly related to this study. The other authors declare that they have no conflict of interest., (© 2024. The Author(s).)

Background: Dementia poses an elevated risk of femoral neck fracture (FNF) in the elderly, often leading to the need for hemiarthroplasty. Yet, the outcomes of hemiarthroplasty in patients who have dementia remain uncertain. The purpose of this study was to assess whether dementia serves as a potential risk factor for outcomes following hemiarthroplasty., Methods: Dementia patients who underwent hemiarthroplasty for FNF with at least 1 year of follow-up were identified using a national insurance database. A 1:1 matched control cohort of patients who do not have dementia was created for comparison. Logistic regression analyses were used to evaluate the rates of complications between the two cohorts. A total of 89,072 patients, of whom half have dementia and half do not, undergoing hemiarthroplasty for FNF were identified., Results: Aside from increased risks of medical complications (P < 0.01), including pneumonia, cerebrovascular accident, acute kidney injury, urinary tract infection, and sepsis, within 90 days, dementia patients also demonstrated higher rates of surgical complications within 1 year, such as dislocation (odds ratio (OR) 1.87, 95% confidence interval (CI) 1.71 to 2.04), periprosthetic fractures (OR 1.29, 95% CI 1.16 to 1.45), and revision (OR 1.23, 95% CI 1.10 to 1.36). On the other hand, dementia patients displayed slightly reduced rates of 90-day deep vein thrombosis and pulmonary embolism. However, no significant increase was found in transfusion, myocardial infarction, wound complications, periprosthetic joint infection, or aseptic loosening between the two cohorts. Additionally, patients who have dementia demonstrated a higher likelihood of 90-day emergency department visits, whereas rates of 90-day hospital readmission remained similar., Conclusions: Although dementia patients do not exhibit an elevated risk of periprosthetic joint infection, or aseptic loosening, they are more prone to experiencing higher risks of prosthetic dislocation, periprosthetic fracture, and revision. Furthermore, specific medical complications tend to be more prevalent among individuals who have dementia., (Copyright © 2024. Published by Elsevier Inc.)

Background: As the incidence of femoral neck fractures (FNFs) increases with the aging population, understanding its impact on surgical outcomes is important to improving implant survival and patient satisfaction. Despite increasing use of total hip arthroplasty (THA) as management for FNF, few studies have examined long-term implant survivability. Thus, this study sought to determine the 10-years cumulative incidence of revision and indications for revision in patients undergoing THA for FNF in comparison to osteoarthritis., Methods: Patients who underwent primary THA for FNF or osteoarthritis were identified using a national administrative claims database and propensity-score matched in a 1:2 ratio based on age, gender, the Charlson Comorbidity Index (CCI), smoking, obesity, and diabetes mellitus. Kaplan-Meier and Cox proportional hazards analyses were used to observe the cumulative incidence and risk of all-cause revision, periprosthetic joint infection (PJI), dislocation, mechanical loosening, and periprosthetic fracture (PPF) within 10 years of primary THA. In total, 19,735 patients who underwent THA for FNF and 39,383 patients who underwent THA for osteoarthritis were included., Results: The 10-years cumulative incidences of all-cause revision (7.1 versus 4.9%), PJI (5.0 versus 3.3%), dislocation (6.8 versus 3.8%), mechanical loosening (3.1 versus 1.9%), and PPF (7.8 versus 4.0%) were significantly higher for those who underwent THA for FNF versus osteoarthritis. Femoral neck fractures were associated with higher risks of revision (hazard ratio [HR]: 1.6), PJI (HR: 1.7), dislocation (HR: 2.0), mechanical loosening (HR: 1.6), and PPF (HR: 2.2) (P < 0.001 for all)., Conclusions: Despite the advantages of THA, femoral neck fractures remain a major risk factor for long-term complications. Tailored preoperative planning, surgical techniques, and postoperative bone health optimization in these patients may help minimize poor outcomes., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Bisphosphonate (BP) use is not uncommon among total hip arthroplasty (THA) candidates. While the impact of BP therapy post-THA has been investigated, there is a paucity of literature discussing the impact of BP therapy pre-THA. Using a national dataset, we aimed to study the association between preoperative BP use and surgical outcomes in primary THA recipients., Methods: This retrospective cohort study used a commercial claims and Medicare Supplemental database to identify adults aged ≥ 18 years who had an index nonfracture-related primary THA from 2016 to 2020. The use of BP was defined as ≥ 6 months of BP therapy in the year prior to THA. Outcomes were 90-day all-cause readmission, 90-day readmission related to periprosthetic fracture (PPF), 90-day and 1-year all-cause revision, 1-year PPF-related revision, and 1-year diagnosis of PPF. In a 1:5 propensity score-matched analysis, each THA patient who had preoperative BP use was matched to five THA patients who did not have preoperative BP use. Logistic regression models were fitted; we report odds ratios (ORs) and 95% confidence intervals (CIs)., Results: Of 91,907 THA patients, 1,018 (1.1%) used BP preoperatively. In the propensity score-matched cohort (1,018 preoperative BP users and 5,090 controls), preoperative BP use was significantly associated with increased odds of 90-day all-cause revision surgery (OR 1.67; 95% CI 1.10 to 2.53; P = 0.02), 1-year PPF-related revision (OR 2.23; 95% CI 1.21 to 4.10; P = 0.01), and 1-year PPF diagnosis (OR 1.88; 95% CI 1.10 to 3.20; P = 0.02). There were no statistically significant associations between preoperative BP use and the other outcomes in the matched cohort., Conclusions: These findings suggest that preoperative BP use is associated with an increased risk of revision surgery and PPF in both the short and long term. This information can help in preoperative planning and patient counseling, potentially leading to improved surgical outcomes and reduced complication rates., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The pelvic and femoral morphology are associated with the occurrence of early periprosthetic femoral fractures (PFFs) in cementless total hip arthroplasty (THA). Differences exist depending on the performed approach and implanted stem design. Therefore, this study was conducted to analyze the pelvic and femoral morphology in cementless short stem THA via a minimally-invasive (MIS) anterolateral approach., Methods: A retrospective, single-center, multi-surgeon, comparative propensity-score matched study of a cohort of 1826 short stem THAs was conducted. A total of 39 PFFs within the first 90 days after surgery was matched on a 2:1 ratio to non-fracture patients. The morphology of the proximal femur was analyzed with canal flare index (CFI), canal-calcar ratio (CCR), canal-bone ratio (CBR), morphological cortical index (MCI), and femoral cortical index (CI). The pelvic morphology was analyzed with ilium-ischial ratio (IR), distance anterior superior iliac spine to the tip of the greater trochanter (AGT). Both groups were analyzed regarding several parameters for femoral and pelvic morphology in non-parametric testing and univariate regression analysis., Results: A significantly higher AGT was detected in the fracture group (104.5 mm ± 18 versus 97.4 mm ± 9.8; p = 0.016). All other femoral and pelvic parameters did not differ between both groups, also when compared depending on the Vancouver type of the PFF., Conclusions: The morphology of the proximal femur and the pelvis do not differ in several radiological parameters in patients sustaining a PFF in cementless short stem THA via an anterolateral approach compared with matched non-fracture group. The findings are controversial to other studies with different stem types and approaches. Future studies should focus on analyzing the influence of the pelvic geometry and the shape of the proximal femur in the occurrence of PFFs in different approaches with the same stem type and vice versa. Level of Evidence Level III case-controlled study., (© 2024. The Author(s).)

Introduction: Peri-implant fractures (PIFs) are uncommon yet critical complications following orthopedic surgery. These complications can significantly impact a patient's psychological well-being and overall quality of life., Aim: This study aimed to investigate the psychological effects of PIFs., Methods: This was a cross-sectional study that involved 136 patients who underwent surgery for PIFs between 2018 and 2022. We utilized various validated scales and questionnaires such as Hospital Anxiety and Depression Scale (HADS), Perceived Stress Scale (PSS), Impact of Event Scale Revised (IES-R), 36-Item Short Form Survey (SF-36), and Brief COPE Inventory (BCI) to assess their psychological state., Result: The results revealed that patients with PIFs experienced higher levels of anxiety, depression, stress, and post-traumatic stress compared to the general population. Additionally, they reported lower physical and mental health. Factors such as the number of surgeries, treatment delay, post-operative pain levels, and complications significantly influenced their psychological outcomes. Notably, acceptance, positive reframing, and seeking emotional support were the most common coping mechanisms employed by these patients. Conversely, denial, substance use, and self blame were the least employed strategies., Conclusion: This study suggests that psychological interventions could significantly benefit patients with PIFs, potentially reducing their distress and improving their quality of life.

Background: Postoperative periprosthetic femoral fracture (POPFF) after total hip replacement (THR) requires complex surgery and is associated with a high morbidity, mortality, and cost. Although the United Kingdom based National Joint Registry (NJR) captures over 95% of THRs treated with revision, before June 2023 it did not capture POPFF treated with fixation. We aimed to estimate the incidence and epidemiology of POPFF treated with either surgery in England., Methods and Findings: We performed a retrospective analysis of a mandatory, prospective database (NJR) linked to Hospital Episode Statistics (HES). All linkable primary THRs between 01/01/2004 and 31/12/2020 were included. Revision or fixation of POPFF were identified using a combination of procedural and diagnosis codes. We identified 809,832 THRs representing 5,542,332 prosthesis years at risk. A total of 5,100 POPFF were identified that had been surgically treated by revision, fixation, or both, and 2,831 of these fractures were treated with fixation alone, meaning 56% were not represented with revision data alone. The incidence of POPFF needing surgery was 0.92 (95% CI 0.90, 0.95) per 1,000 prostheses years. This incidence was higher in patients over the age of 70 at the time of primary THR (1.31 [95% CI 1.26, 1.35] per 1,000 prostheses years) and for patients who underwent THR for hip fracture (2.19 [95% CI 1.97, 2.42] per 1,000 prostheses years). This incidence appears to be increasing year on year. The cumulative probability of sustaining a POPFF within 10 years of THR was 1% and over 15% of patients died within 1 year of surgery for a POPFF., Conclusions: To date, the incidence of POPFF may have been underestimated with over 50% of cases missed if the case identification in this study is correct. After including these cases, we observed that POPFF is the largest reason for major reoperation following THR and patients sustaining these injuries have a high risk of death. The prevention and treatment of POPFF and requires further resource allocation and research., Competing Interests: HP is a NIHR senior investigator and MHRA advisor. In the latter role, he advised MHRA regarding the incidence and risk factors associated with the post-operative peri-prosthetic femoral fractures. In particular, this was to identify the risks associated with one of the commonly used stems (CPT manufactured by Zimmer Biomet). This was a voluntary role and no funding from MHRA was/is associated with it. HP (as a Chief Investigator) receives institutional funding from Zimmer Biomet, Depuy Synthes, Allay Therapeutics, Paradigm Pharma and Invibio. In particular, Zimmer Biomet has funded University of Leeds in relation to the on-going and previous research in the field of peri-prosthetic fractures. HP is a paid consultant to Zimmer Biomet for the work in the field of peri-prosthetic fractures and arthroplasty related teaching / training. HP has also received personal funding from the following industry organisations (unrelated to the topic of this work): Invibio, Medacta International, Smith and Nephew, MATOrtho, Microport, Teleflex, Allay Therapeutics and Paradigm Pharmaceuticals. HP has a stock option with Allay Therapeutics. HP holds two patents (through University of Leeds - in the field of implantable sensors and recharging apparatus). None of these roles / funding from any of the industry organisations (either to HP or to his institution) influenced the design; collection, analysis, and interpretation of data presented in this manuscript), (Copyright: © 2024 Lamb et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Periprosthetic knee fractures (PPKFs) following total knee arthroplasty (TKA) are uncommon, but potentially serious injuries. We analyze the risk and risk factors for a PPKF in standard primary TKA patients who have osteoarthritis and a minimally (cruciate-retaining TKAs without a femoral box cut) or posterior-stabilized TKA. In addition, we report the risk for patients who have other underlying knee disorders and/or a higher level of TKA constraint., Methods: All primary TKAs were identified from the Danish National Patient Register and the Danish Knee Arthroplasty Register using data between 1997 and 2022. Subsequent fractures were identified through the International Classification of Diseases diagnosis code, Nordic Medico-Statistical Committee procedure code, or indication for revision TKA., Results: We included 120,642 standard primary TKA patients who had 1,659 PPKFs. The cumulated proportions were 0.4% (95% confidence interval (CI) 0.3 to 0.4) at 2 years 0.8% (0.7 to 0.8) at 5 years. At 10 years, the cumulated proportion was 1.7% (1.6 to 1.8), with 1.3% in the femur, 0.2% in the patella, and 0.2% in the tibia. Significant risk factors were (hazard ratio [HR] [95% CI]); ipsilateral hip arthroplasty (2.3 [2.0 to 2.6]); women (2.1 [1.8 to 2.4]), osteoporosis (1.4 [1.2 to 1.7]); age 80+ (1.4 [1.3 to 1.6]), uncemented TKA (1.3 (1.1 to 1.5) and Charlson Comorbidity Index score 3+ (1.4 [1.1 to 1.8]). An additional 22,624 primary TKA patients who had other underlying knee disorders and/or a higher level of implant constraint were included with 633 PPKFs. The 10-year cumulated proportions were 8.3% (95% CI 6.9 to 9.8) when the underlying disorder was a previous fracture, 2.8% (2.2 to 3.5) for rheumatic disorders, and 5.2% (2.6 to 10.6) for osteonecrosis. In patients who had condylar constrained knees, it was 6.9% (5.1 to 9.4), and 12.4% (8.0 to 16.04) for hinges., Conclusions: In standard primary TKA patients, the 10-year cumulated proportion of PPKFs was 1.7%, and ipsilateral hip arthroplasty, women, osteoporosis, advanced age, uncemented TKA and higher Charlson Comorbidity Index increased the risk. Higher risks were observed in non-osteoarthritis patients and/or patients who had a higher level of TKA constraint., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The present study aimed to identify the risk factors of periprosthetic femoral fracture (PFF) after cementless total hip arthroplasty and rank them based on importance., Methods: The age, sex, body mass index (BMI), osteoporosis, canal flare index (CFI), canal bone ratio (CBR), canal calcar ratio (CCR), stem design, and stem canal fill ratio (P1, P2, P3, and P4) of the proximal femoral medullary cavity of 111 total hip arthroplasty patients who had PFF and 388 who did not have PFF were analyzed. Independent-samples student t-tests were used for continuous variables, and Chi-square tests were used for categorical variables. The importance rankings of influencing factors were assessed using a random forest algorithm. Dimensionally reduced variables were then incorporated into a binary logistic regression model to determine the PFF-related risk factors., Results: The mean age, BMI, CBR, CCR, and incidence of osteoporosis were higher in cases of PFF (all P < .001), while the mean CFI, P1, P2, P3, and P4 were lower in cases of PFF (P < .001, P = .033, P = .008, P < .001, and P < .001, respectively). Additionally, the stem design was also statistically associated with PFF (P < .001). Multivariate logistic regression revealed that advanced age, higher BMI, osteoporosis, stem design, lower CFI, higher CBR, higher CCR, lower P1, lower P2, lower P3, and lower P4 were the risk factors of PFF (P < .001, P < .001, P < .001, P < .001, P < .001, P = .010, P < .001, P = .002, P < .001, P < .001, and P = .007, respectively). The ranked importance of the risk factors for PFF was P3, CFI, osteoporosis, CBR, age, P4, P1, stem design, CCR, BMI, and P2., Conclusions: Lower P3, lower CFI, osteoporosis, higher CBR, advanced age, lower P4, lower P1, stem design, higher CCR, higher BMI, and lower P2 increased the risk of PFF., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: With the rise in elderly populations, the incidence of femoral trochanteric fractures has also increased. Although intramedullary nail therapy is commonly used, the incidence of peri-implant fractures (PIFs) as a complication and its associated factors are not fully understood. The purpose of this study was to determine the incidence of PIFs and treatment strategies and outcomes., Methods: A retrospective study across 11 hospitals from 2016 to 2020 examined 1855 patients with femoral trochanter fracture. After excluding 69 patients treated without intramedullary nailing, 1786 patients were analyzed. Parameters studied included age, sex, body mass index, medical history, and treatment methods. PIFs were categorized using the Chan classification. Treatment outcomes and patient mobility were assessed using the Parker Mobility Score, and postoperative complications and one-year survival data were compiled., Results: The incidence of PIFs was 8 in 1786 cases. Chan classification showed 1 case of N1A, 6 of N2A, and 1 of N2B. Only the type N1 case was a transverse fracture, whereas all cases of type N2 were oblique fractures. Among these cases, five patients had fractures extending to the upper part of the femoral condyle. The patient with N1A and one bedridden patient with N2A fracture underwent conservative treatment, one patient with N2A in which the fracture did not extend to the condyle was treated with nail replacement, and 5 patients (N2A: 4, N2B: 1) with fractures extending to the condyle were treated with additional plate fixation. All patients had survived at one year after treatment for PIF, and no reoperations were required., Conclusions: The incidence of PIF was very low (0.45%). Of the 6 PIF cases, excluding the bedridden patients, the treatment of choice for PIF was an additional plate if the fracture line extended to the femoral condyle; otherwise, the nail was replaced. All patients achieved bony fusion., Level of Evidence: Therapeutic Level IV., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Patients who sustain fragility fractures prior to total shoulder arthroplasty have significantly higher risk for bone health-related complications within 8 years of procedure. Identification of these high-risk patients with an emphasis on preoperative, intraoperative, and postoperative bone health optimization may help minimize these preventable complications., Purpose: As the population ages, more patients with osteoporosis are undergoing total shoulder arthroplasty (TSA), including those who have sustained a prior fragility fracture. Sustaining a fragility fracture before TSA has been associated with increased risk of short-term revision rates, periprosthetic fracture (PPF), and secondary fragility fractures but long-term implant survivorship in this patient population is unknown. Therefore, the purpose of this study was to characterize the association of prior fragility fractures with 8-year risks of revision TSA, periprosthetic fracture, and secondary fragility fracture., Methods: Patients aged 50 years and older who underwent TSA were identified in a large national database. Patients were stratified based on whether they sustained a fragility fracture within 3 years prior to TSA. Patients who had a prior fragility fracture (7631) were matched 1:1 to patients who did not based on age, gender, Charlson Comorbidity Index (CCI), smoking, obesity, diabetes mellitus, and alcohol use. Kaplan-Meier and Cox Proportional Hazards analyses were used to observe the cumulative incidences of all-cause revision, periprosthetic fracture, and secondary fragility fracture within 8 years of index surgery., Results: The 8-year cumulative incidence of revision TSA (5.7% vs. 4.1%), periprosthetic fracture (3.8% vs. 1.4%), and secondary fragility fracture (46.5% vs. 10.1%) were significantly higher for those who had a prior fragility fracture when compared to those who did not. On multivariable analysis, a prior fragility fracture was associated with higher risks of revision (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.24-1.74; p < 0.001), periprosthetic fracture (HR, 2.98; 95% CI, 2.18-4.07; p < 0.001) and secondary fragility fracture (HR, 8.39; 95% CI, 7.62-9.24; p < 0.001)., Conclusions: Prior fragility fracture was a significant risk factor for revision, periprosthetic fracture, and secondary fragility fracture within 8 years of primary TSA. Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize these complications., Level of Evidence: III., (© 2024. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Purpose: In patients undergoing hemiarthroplasty in the elderly, the choice of the cemented method remains controversial. This meta-analysis was undertaken to compare the impact of cemented vs uncemented on outcomes for hemiarthroplasty in the elderly., Methods: This study included randomized controlled trials comparing the postoperative effects of cemented vs uncemented in patients with hemiarthroplasty. With no language restrictions, we searched Medline (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials (Cochrane Collaboration), Clinical Trials.gov, the ISRCTN registry, as well as gray literature with no language restrictions from January 1966 to April 2023. Data were quantitatively summarized using a random-effects model. The primary outcome was 1-year mortality., Results: This study included 13 randomized controlled trials with 3485 patients. The primary outcomes of the meta-analysis showed that cemented fixation in elderly patients undergoing hemiarthroplasty was superior to noncemented in 1-year mortality (risk ratio [RR] = 0.87, 95% confidence interval [CI]: 0.77, 0.97). Moreover, cemented was associated with a reduced risk of intraoperative periprosthetic fracture (RR = 0.19, 95% CI: 0.07, 0.50), postoperative periprosthetic fracture (RR = 0.34, 95% CI: 0.16,0.72), and loosening (RR = 0.33, 95% CI: 0.11, 0.97)., Conclusions: Cemented hemiarthroplasty is superior to noncemented in terms of survival. Moreover, cementation reduces the incidence of some implant-related complications. More extensive trials are needed to provide adequate guidance for choosing the proper cemented method., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: An increased risk of periprosthetic fracture and aseptic loosening is reported when the direct anterior approach (DAA) is used for total hip arthroplasty (THA), especially with cementless implants. We assessed the rate of revision comparing collared and collarless femoral stems when using the DAA for THA., Methods: We used data from the Australian Orthopaedic Association National Joint Replacement Registry for primary THA for osteoarthritis inserted with the DAA between January 2015 and December 2022. There were 48,567 THAs that used the DAA (26,690 collarless cementless, 10,161 collared cementless, and 11,716 cemented). Cumulative percent revision was calculated for all-cause revision, revision for periprosthetic femoral fractures, and aseptic femoral stem loosening. Cox proportional hazard ratios [HRs] were used to compare the revision of collared and collarless cementless stems. We also compared collared cementless stems and cemented stems., Results: A higher rate of all-cause revision within 3 months of surgery was observed with collarless compared to collared cementless implants (HR: 1.99 [95% confidence interval (CI), 1.56 to 2.54]; P < .001). Similarly, collarless cementless implants were associated with a greater rate of revision for fracture in the first 6 months (HR: 2.90 [95% CI, 1.89 to 4.45]; P < .001) and after 6 months (HR 10.04 [95% CI 1.38 to 73.21]; P = .02), as well as an increased rate of revision for aseptic loosening after 2 years (HR: 5.76 [95% CI, 1.81 to 18.28], P = .003). Collared cementless and cemented stems performed similarly., Conclusion: Collared stems were associated with a reduced rate of all-cause revision for cementless THA performed via the DAA. The reduction in risk may be due to protection from periprosthetic femoral fracture and aseptic loosening., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: This investigation examined cemented femoral component use in total hip arthroplasty (THA) and its impact on the incidence of periprosthetic fractures (PPFx), a common failure mode in THA. The study leverages data from the American Joint Replacement Registry (AJRR) to assess trends in cemented femoral component usage over time, its association with PPFx rates, and compares the survivorship and 90-day complication rates between cemented and cementless femoral component THAs., Methods: Primary THAs, captured in the AJRR, in patients aged 65 years and older from 2012 to 2021 were analyzed. Variables considered included age, sex, race, region, teaching status, year, Charlson comorbidity index, and institution bed size. Analysis compared fixation types for THA on all-cause linked revision and PPFx. Logistic regression models analyzed the odds ratios for all-cause linked revision and PPFx for any follow-up time as well as for 90-day revision. The models were adjusted for the listed variables., Results: During the study period, the rate of cement utilization as a percentage of primary THAs performed and reported to the AJRR increased from 4.4 to 8.3%. The rate of THA failure from PPFx increased from 11.4 to 33.3%. When both fixation groups were compared in the univariate analysis, there was a statistically significant difference in all demographic variables (P < .001). To account for this, multivariable logistic regression models were applied. In our models, cemented stems showed a 54.4% (odds ratio: 0.456; 95% confidence interval: 0.347 to 0.599; P < .0001) and 65.8% (odds ratio: 0.342; 95% confidence interval: 0.237 to 0.493; P < .0001) lower risk of PPFx linked and PPFx early linked revision, respectively., Conclusions: Periprosthetic fractures are becoming a leading failure mode for THAs in the AJRR. Given cemented fixation's relative resistance to this failure mode compared to cementless fixation, we should consider increasing the utilization of this technique., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to compare outcomes between acute, subacute, and delayed arthroplasty for acetabular fractures occurring within 1 week, from 1 week to 6 months, or more than 6 months before the index total hip arthroplasty (THA), versus THA without a history of acetabular fracture as a control., Methods: We analyzed the records of patients undergoing primary THA who were enrolled in a national database for at least 2 years before and after the index procedure. Patients who had an initial diagnostic code for acetabular fracture occurring less than 1 week, from 1 week to 6 months, or at least more than 6 months before the THA were classified as acute THA (aTHA), subacute THA (saTHA), or delayed THA (dTHA), respectively. The control group was patients undergoing THA who did not have a history of acetabular fracture. There were 430,349 control primary THAs, 462 aTHAs, 675 saTHAs, and 1,162 dTHAs., Results: After adjusting for age, sex, region, and comorbidities, patients who had an aTHA and saTHA experienced statistically significant increased odds of revision, dislocation, and periprosthetic fracture compared to primary THA without a history of acetabular fracture. Similarly, dTHA was associated with increased odds of revision, dislocation, and periprosthetic fractures compared to primary THA. In the multivariate analysis, aTHA had statistically significant higher rates of dislocation when compared to dTHA., Conclusions: Patients who had a history of acetabular fractures undergoing aTHA, saTHA, or dTHA have significantly increased rates of revision, periprosthetic fracture, and dislocation compared to primary THA in those who did not have a history of acetabular fractures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Oral corticosteroids are the primary treatment for several autoimmune conditions. The risk of long-term implant, bone health, and infectious-related complications in patients taking chronic oral corticosteroids before total knee arthroplasty (TKA) is unknown. We compared the 10-year cumulative incidence of revision, periprosthetic joint infection (PJI), fragility fracture (FF), and periprosthetic fracture following TKA in patients who had and did not have preoperative chronic oral corticosteroid use., Methods: A retrospective cohort analysis was conducted using a national database. Primary TKA patients who had chronic preoperative oral corticosteroid use were identified using Current Procedural Terminology and International Classification of Disease 9 and 10 codes. Exclusion criteria included malignancy, osteoporosis treatment, trauma, and < 2-year follow-up. Primary outcomes were 10-year cumulative incidence and hazard ratios (HRs) of all-cause revision (ACR), aseptic revision, PJI, FF, and periprosthetic fracture. A Kaplan-Meier analysis and a multivariable Cox proportional hazards model were utilized. Overall, 611,596 patients were identified, and 5,217 (0.85%) were prescribed chronic corticosteroids. There were 10,000 control patients randomly sampled for analysis., Results: Corticosteroid patients had significantly higher 10-year HR of FF (HR; 95% confidence interval); P value (1.47; 1.34 to 1.62; P < .001)], ACR (1.21; 1.05 to 1.40; P = .009), and PJI (1.30; 1.01 to 1.69; P = .045) when compared to the control., Conclusions: Patients prescribed preoperative chronic oral corticosteroids had higher risks of ACR, PJI, and FF within 10 years following TKA compared to patients not taking corticosteroids. This information can be used by surgeons during preoperative counseling to educate this high-risk patient population about their increased risk of postoperative complications., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Total hip arthroplasty (THA) aims to restore joint function and relieve pain. New technology, such as robot assistance, offers the potential to reduce human error, improve precision, and improve postoperative outcomes. The aim of this study was to compare outcomes between conventional and robot-assisted THA., Methods: This is a retrospective cohort study utilizing a national database from 2016 to 2019. Patients undergoing THA, conventional or robot-assisted, were identified via the International Classification of Diseases, Tenth Revision code. Multivariate regressions were performed to assess outcomes between groups. Negative binomial regressions were performed to assess discharge disposition, readmission, and reoperation. Gamma regressions with log-link were used to assess total charges and lengths of hospital stays. Patient demographics and comorbidities, measured via the Elixhauser comorbidity index, were controlled for in our analyses. A total of 1,216,395 patients undergoing THA, 18,417 (1.51%) with robotic assistance, were identified., Results: Patients undergoing robot-assisted procedures had increased surgical complications (odds ratio [OR] 1.31 [95% confidence interval [CI] 1.14 to 1.53]; P < .001), including periprosthetic fracture (OR 1.63 [95% CI 1.35 to 1.98]; P < .001). Notably, these patients also had significantly greater total charges (OR 1.20 [95% CI 1.11 to 1.30]; P < .001)., Conclusions: Robotic assistance in THA is associated with an increased risk of surgical complications, including periprosthetic fracture, while incurring greater charges., Study Design: Level III; Retrospective Cohort Study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Cementless femoral fixation in total hip arthroplasty (THA) has increased in prevalence worldwide. However, cementless fixation in elderly patients is controversial due to the risks of periprosthetic fracture and aseptic loosening. This study evaluated outcomes in patients undergoing primary THA utilizing a cementless stem without a collar, comparing those less than 75 years to those older than 75 years., Methods: Between 2011 and 2021, there were 2,605 cementless THAs performed by 4 surgeons utilizing a highly porous metal fixation surface without a collar and consistent clinical protocols. There were 469 patients who had an age ≥ 75 years. Revision rates, intraoperative fractures, and 90-day mortality were compared between cohorts. In the ≥ 75 year age group, there were more women, more American Society of Anesthesiologists physical status classification III or IV, a lower body mass index, and more kidney disease, osteoporosis, and thyroid disease (P ≤ .002)., Results: All-cause revision rates trended lower for the ≥75 year age group compared to < 75 year (1.9 versus 3.5%, P = .082) at 20-months of follow-up. Moreover, there was no difference in all-cause femoral component revisions comparing ≥ 75 to < 75 year age groups (1.5 versus 2.2%, P = .375), with only 3 of 10 femoral revisions due to aseptic loosening being in the ≥ 75 year age group. Intraoperative fracture (0.2 versus 0.5%, P = .701) and 90-day mortality (0.2 versus 0.1%, P = .460) did not differ between ≥ 75 and < 75 year age groups., Conclusions: Older patients had comparable revision rates compared to younger patients using cementless femoral fixation without a collar. Furthermore, there was no difference in 90-day mortality or intraoperative fracture rates. Study findings provide evidence for the safety and durability of cementless THA using collarless femoral stems in elderly patients ≥ 75 years of age., Level of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: The increasing prevalence of primary hip arthroplasty has led to a parallel rise in revision cases. Femoral revision often entails compromised bone integrity, requiring consideration of various solutions for optimal reconstructive options. Despite technological advancements, there is limited evidence on the clinical outcomes of the latest modular revision stems. This study aimed to evaluate the clinical outcomes and survival rates of next generation uncemented modular revision stem in patients undergoing hip revision surgery., Materials and Methods: This retrospective single-center study assessed the survival and failure causes of a specific uncemented modular stem in 48 patients undergoing hip revision surgery between 2012 and 2022. Data included preoperative parameters, surgical details, and postoperative outcomes measured through clinical and radiographic assessments. Forty-eight patients (25 males, 23 females; mean age 72 years) were included, with a mean Charlson Comorbidity Index of 5. Preoperative diagnoses varied, with periprosthetic joint infection (PJI) being the most common (45.8%), followed by periprosthetic fractures (27.1%). Partial revisions occurred in 60.4%, total revisions in 39.6%. According to Paprosky classification of femoral bone loss, type II and III were the most represented, respectively 35.4% and 50%., Results: At a mean follow-up of 4.6 years, stem survival was 92.5%. Complications (20%) included dislocation, PJI, fracture, and loosening; the overall reoperation rate was 12.5%. The SF-12 physical score was 43.6, while the mental score was 51.1. The HOOS score was 71.8, and the HHS score was 71.4. Radiographic analysis identified nonprogressive osteolysis in 15.1% of patients., Conclusions: This study on this uncemented modular revision stem demonstrated favorable outcomes in an elder fragile population with moderate to severe femoral bone loss. The implant's modularity provides versatility in addressing various defects, without any implant breakage observed during the study period. Literature comparison highlighted similar outcomes despite sample size differences. The promising results warrant continued investigation into the long-term survivorship of this modular stem system., (© 2024. The Author(s).)

Background: In the last years, there has been increasing use of shoulder arthroplasty. As a result, an increasing incidence of periprosthetic humerus fractures (PPHF) is expected. Therefore, this retrospective, multicenter analysis aimed to collect demographic data from patients with PPHF, their treatment strategies, and associated complications., Methods: Demographics of patients with PPHF were collected retrospectively from the database of six trauma hospitals between January 2000 and December 2020. All fractures were categorized according to the Wright and Cofield, and Worland classifications. In addition, the type of treatment for PPHF, as well as subsequent complications, were evaluated., Results: A total of 72 patients with a PPHF were identified. The mean age of the 55 female and 17 male patients was 77 years. PPHF occurred a mean of 50 months after primary arthroplasty implantation, almost exclusively as a result of a fall from standing height (n = 67). In-situ implant was a RTSA in 40 patients and a hemiarthroplasty in 32 patients. More than half of the fractures (n = 38) were type B fractures, according to Wright and Cofield. According to Worland, the majority of patients also had a type B fracture (type B1 (n = 22), type B2 (n = 28), type B3 (n = 10)). Associated comorbidities were found in 21 patients. A total of 31 patients were treated non-operatively, 27 with Open Reduction Internal Fixation (ORIF), and 14 with a revision arthroplasty. Nine primary radial nerve palsies were found (pre-operatively), and seven secondarily (post-operatively). Nine patients suffered from non-union (ORIF 4, non operative 4, stem replacement 1)., Conclusion: The treatment strategy for PPHF is primarily tailored to the individual patient. Decisive factors such as patient's age, fracture type, and primary palsies have to be considered for optimal treatment. In type B1 fractures, there is a recommendation for ORIF because of high non-union rates under non-operative treatment. In contrast, in type B2 fractures, a non-operative approach should be preferred, provided there are no radial nerve lesions., Level of Evidence: Level IV, epidemiologic study., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Periprosthetic fractures are rare but serious complications of unicompartmental knee arthroplasty (UKA). Although cementless UKA has a lower risk of loosening than cemented, there are concerns that tibial fracture risk may be higher given the reliance on interference fit for primary stability. The risk of fracture and the effect of surgical fixation are currently unknown. We compared the periprosthetic fracture rate following cemented and cementless UKA surgery., Methods: A total of 14,122 medial mobile-bearing UKAs (7,061 cemented and 7,061 cementless) from the National Joint Registry and Hospital Episodes Statistics database were propensity score-matched. Cumulative fracture rates were calculated and Cox regressions were used to compare fixation groups., Results: The three-month periprosthetic fracture rates were similar (P = .80), being 0.10% in the cemented group and 0.11% in the cementless group. The fracture rates were highest during the first three months postoperatively, but then decreased and remained constant between one and 10 years after surgery. The one-year cumulative fracture rates were 0.2% (confidence interval [CI]: 0.1 to 0.3) for cemented and 0.2% (CI: 0.1 to 0.3) for cementless cases. The 10-year cumulative fracture rates were 0.8% (CI: 0.2 to 1.3) and 0.8% (CI: 0.3 to 1.3), respectively. The hazard ratio during the whole study period was 1.06 (CI: 0.64 to 1.77; P = .79)., Conclusions: The periprosthetic fracture rate following mobile bearing UKA surgery is low, being about 1% at 10 years. There were no significant differences in fracture rates between cemented and cementless implants after matching. We surmise that surgeons are aware of the higher theoretical risk of early fracture with cementless components and take care with tibial preparation., Levels of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Utilization of the direct anterior approach (DAA) for total hip arthroplasty (THA) has been steadily increasing in recent years. While the DAA may offer some benefits compared to other approaches, there are still risks involved including relatively higher rates of periprosthetic femur fractures, especially when combined with cementless femoral stem use. The purpose of this study is to evaluate the early postoperative femoral complications with a short triple-wedge tapered stem used in primary THA via a DAA., Materials and Methods: A retrospective review was conducted of the arthroplasty registry of our institution from April 2022 to August 2023 to identify patients who underwent a primary THA via a DAA with the Short Medacta Stem (SMS) (Medacta International, Castel San Pietro, Switzerland). Patients were excluded if the stem was used for a revision surgery, they were within 90 days of surgery, or they refused research consent. Inclusion criteria was met in 262 patients (302 hips). Data was collected after reviewing the chart, and reports and radiographic measurements, including Dorr type and canal fit ratios, were obtained from preoperative and postoperative radiographs, respectively., Results: A total of 302 total hips were included, 161 patients were male (53.3%) and 141 were female (46.7%), with an average age of 66.5 years (27-88, +/- 10.7 years). Average follow up was 0.3 years (range, 0.05-1.71 years). The majority of patients had a Dorr B femur (81.7%). The Median stem size used was an 8 (range, 2-15), and 89.4% of those had a collar. Average canal fill ratio was 0.83 (range, 0.43-0.98, +/- 0.07). Overall, there were two Vancouver B2a periprosthetic femoral shaft fractures (0.66%) that required revision surgery to a modular stem. In addition, there were two Vancouver Ag greater trochanteric fractures (0.66%) with acceptable alignment that did not require revision surgery. Demographic information about the patients with femoral complications is summarized in Table I. Average age of patients with femoral complications was 69.5 years, with an average canal fit ratio of 0.88., Conclusion: We found that the triple-wedge implant had a low rate of early femoral complication in primary THA from an anterior approach and is safe for use in THA from a DAA. More follow up is needed to evaluate continuing implant survivorship and patient outcomes.

Context: Osteoporosis is a prevalent concern, particularly among aging populations, leading to increased risk of fractures, including those related to hip and knee arthroplasty procedures. Screening for osteoporosis, especially with dual X-ray absorptiometry (DXA) scans, is crucial for early detection and management., Objectives: This study aimed to assess adherence to osteoporosis screening guidelines among patients aged 65 and older undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) within a single health network. Factors influencing screening adherence were also explored., Methods: A retrospective chart review of 2,160 patients undergoing elective THA or TKA between January 2019 and January 2023 was conducted. Demographic data, osteoporosis screening status, and occurrence of periprosthetic fractures were analyzed. Statistical analysis included descriptive statistics and chi-square tests., Results: Only 24.1 % of eligible patients underwent a DXA scan prior to surgery. Females were more likely to undergo screening than males, and race was also associated with screening status. A total of 45 periprosthetic fractures were identified, with no significant correlation between osteoporosis status, DXA screening, and fracture occurrence., Conclusions: Adherence to osteoporosis screening guidelines among geriatric patients undergoing elective total joint arthroplasty remains low within the studied health network. Despite the lack of correlation between screening and fracture occurrence in this study, the importance of screening and potential optimization in high-risk patients is emphasized. Further research is needed to assess outcomes associated with different care pathways in bone health screening and management for elective geriatric total joint patients., (© 2024 the author(s), published by De Gruyter, Berlin/Boston.)

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., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Periprosthetic femoral fractures (PPFFs) represent an important healthcare problem, with a rising incidence noted due to an increase in the number of arthroplasty surgeries being performed. There is a current lack of national consensus as to how these complex, often frail patients are managed., Aims: Our primary aim was to present the epidemiology of PPFFs in England and Wales over the first two years of data collection by the National Hip Fracture Database (NHFD). Secondary aims included how well the NHFD Key Performance Indicators (KPIs) are met for PPFF patients, whether centres reporting a higher burden of PPFF patients are more likely to meet KPIs compared to lower volume centres, and to also identify if regional variation in care for these patients exist., Methods: Patients aged 60 years or over, admitted to any acute hospital in England or Wales with a PPFF within the period 1st January 2020 to 31st December 2021 were included. Fractures were classified using the Vancouver system. The primary outcome of interest was the incidence of PPFF in England and Wales. Secondary outcomes included i) geographical distribution, ii) pattern of injury, iii) treatment received, iv) KPI performance nationally, v) KPI performance by top 5 highest volume hospitals vs the rest, vi) KPI performance by region and vii) KPI performance compared with native hip fracture patients., Results: A total of 5,566 PPFFs were reported during our study period. A 31 % increase in cases was seen between 2020 and 2021 (2,405 to 3,161). The South-West of England reported the highest burden of PPFFs (14 % of all cases reported in 2021). Vancouver B subtypes were most common around hip replacements (62 %) and C subtype around knee replacements (55 %). A total of 4,598 patients (82.6 %) underwent operative management. There was regional variation in KPI attainment. When compared to KPI attainment for native hip fractures PPFF care under performed in most regions and domains. High volume PPFF centres were not associated with improved attainment of KPIs., Conclusion: We have described the incidence, nature, and management of PPFF at national and regional levels using routinely collected NHFD data. Both numerically and due to case complexity, PPFF are a considerable challenge to patients and health services alike. This epidemiology is not captured by other existing datasets and increased case contribution to the NHFD is encouraged to improve understanding and enable prioritisation and delivery of further care and research., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare, (Copyright © 2024. Published by Elsevier Ltd.)

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., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This report provides an updated analysis for patients with osteoporosis following total hip arthroplasty (THA). The comorbidities of alcohol abuse, chronic kidney disease, cerebrovascular disease, obesity, and rheumatoid arthritis continue to be significant risk factors for periprosthetic femur fracture (PPFFx) and aseptic loosening in the population with osteoporosis. Patients with dual-energy x-ray absorptiometric (DEXA) scans were at risk for PPFFx regardless of femoral fixation method, and patients with DEXA scans with cementless fixation were at risk of aseptic loosening after THA. The patient population with severe osteoporosis may have higher risks for aseptic loosening and PPFFx than previously recognized., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Periprosthetic fractures can be devastating complications after total joint arthroplasty (TJA). The management of periprosthetic fractures is complex, spanning expertise in arthroplasty and trauma. The purpose of this study was to examine and project trends in the operative treatment of periprosthetic fractures in the United States., Methods: A large, public and private payer database was queried to capture all International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for periprosthetic femoral and tibial fractures. Statistical models were created to assess trends in treatment for periprosthetic fractures and to predict future surgical rates. An alpha value of 0.05 was used to assess significance. A Bonferroni correction was applied where applicable to account for multiple comparisons., Results: In this study, from 2016 to 2021, 121,298 patients underwent surgical treatment for periprosthetic fractures. There was a significant increase in the total number of periprosthetic fractures. The incidence of periprosthetic hip fractures rose by 38% and that for periprosthetic knee fractures rose by 73%. The number of periprosthetic fractures is predicted to rise 212% from 2016 to 2032. There was a relative increase in open reduction and internal fixation (ORIF) compared with revision arthroplasty for both periprosthetic hip fractures and periprosthetic knee fractures., Conclusions: Periprosthetic fractures are anticipated to impose a substantial health-care burden in the coming decades. Periprosthetic knee fractures are predominantly treated with ORIF rather than revision total knee arthroplasty (TKA), whereas periprosthetic hip fractures are predominantly treated with revision total hip arthroplasty (THA) rather than ORIF. Both periprosthetic knee fractures and periprosthetic hip fractures demonstrated increasing trends in this study. The proportion of periprosthetic hip fractures treated with ORIF relative to revision THA has been increasing., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H943)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: The increase in hip arthroplasties predicts a rise in periprosthetic fractures in Morocco, posing challenges for orthopedic surgeons. Therapeutic strategies vary considerably, highlighting the absence of a universally accepted treatment protocol., Aim: To analyze the management of per-prosthetic hip fractures, while addressing the challenges associated with them., Methods: This was a retrospective study, conducted in the trauma-orthopedics department between December 2015 and November 2022. Nineteen patients who presented to the hospital with fractures around a hip prosthesis were included., Result: Nineteen periprosthetic fractures were observed. The majority of patients (68%) were women, with an average age of 68. The Vancouver classification showed that 52.6% of the fractures were type B1, and 21.1% type C, while the other fracture types were distributed differently. These fractures were mainly associated with diagnoses such as femoral neck fracture (63.2%) and coxarthrosis (31.6%). We observed variations in treatment recommendations and results between the different series analyzed. We noted discrepancies with certain series concerning fracture types and therapeutic choices. However, in our series, we achieved satisfactory results, with successful consolidation and the absence of complications in all patients., Conclusion: These results underline the importance of an individualized approach to fracture management, taking into account the specificities of each case.

Background: Periprosthetic fractures are serious complications of knee arthroplasty often requiring complex surgery. There is concern of increased periprosthetic fracture risk with cementless components given the reliance on interference fit for primary stability. It is unknown how the periprosthetic fracture risk compares between cemented and cementless total knee arthroplasties (TKAs)., Methods: A total of 22,477 cemented and 22,477 cementless TKAs from the National Joint Registry and Hospital Episodes Statistics database were propensity score matched on patient and surgical factors. Cumulative periprosthetic fracture rates were calculated using Kaplan-Meier analyses and compared with Cox regressions. Subgroup analyses were performed in different age, body mass index, and sex groups., Results: The 3-month fracture rate in the cemented and cementless TKA groups were 0.02% and 0.04%, respectively. At 10 years, the cumulative fracture rate after cemented TKA was 1.2%, and after cementless was 1.4%. During the study period, there were no significant differences in fracture rates between cemented and cementless TKAs with a hazards ratio 1.14 (confidence interval 0.94 to 1.37, P = .20) at 10 years postoperatively. There were no significant differences in fracture rates between fixation types on subgroup analyses of sex, body mass index, and age groups. Female sex was a risk factor for fracture in both cemented (odds ratio 2.35, P < .001) and cementless TKAs (odds ratio 2.97, P < .001)., Conclusions: The periprosthetic fracture rates following cemented and cementless TKA surgery are low being approximately 1.2% and 1.4%, respectively at 10 years. There were no significant differences in periprosthetic fracture rates requiring readmission between cemented and cementless TKAs., Level of Evidence: III., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Periprosthetic fractures following total hip arthroplasty (THA) often occur in the early postoperative period. Recent data has indicated that early revisions are associated with higher complication rates, particularly periprosthetic joint infection (PJI). The purpose of this study was to assess the effect of timing of periprosthetic fracture surgery on complication rates. We hypothesized that complication rates would be significantly higher in revision surgeries performed within 3 months of the index THA., Methods: The Medicare Part A claims database was queried from 2010 to 2017 to identify patients who underwent surgery for a periprosthetic fracture following primary THA. Patients were divided based on time between index and revision surgeries: <1, 1 to 2, 2 to 3, 3 to 6, 6 to 9, 9 to 12, and >12 months. Complication rates were compared between groups using multivariate analyses to adjust for demographics, comorbidities, and types of revision surgery., Results: Of 492,340 THAs identified, 4,368 (0.9%) had a subsequent periprosthetic fracture requiring surgery: 1,725 (39.4%) at <1 month, 693 (15.9%) at 1 to 2 months, 202 (4.6%) at 2 to 3 months, 250 (5.7%) at 3 to 6 months, 134 (3.1%) at 6 to 9 months, 85 (19.4%) at 9 to12 months, and 1,279 (29.3%) at >12 months. The risk of PJI was 11.0% in the <1 month group, 11.1% at 1 to 2 months, 7.9% at 2 to 3 months, 6.8% at 3 to 6 months, 8.2% at 6 to 9 months, 9.4% at 9 to 12 months, and 8.5% at >12 months (P = .12). Adjusting for confounding factors, risk of PJI following periprosthetic fracture surgery was similar regardless of timing (P > .05). Rates of subsequent dislocation and aseptic loosening were also similar regardless of timing., Conclusions: The risk of PJI following repeat surgery for a periprosthetic fracture was strikingly high regardless of timing (6.8 to 11.1%), underscoring the high-risk of complications., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Osteonecrosis of the femoral head (ONFH) affects both young and old patients. However, outcomes following total hip arthroplasty (THA) for these patients may vary with age. This study aimed to examine the effect of age on THA outcomes for non-traumatic ONFH patients, an area currently lacking research., Methods: Patients who had non-traumatic ONFH undergoing THA with at least 2 years of follow-up were identified using a database and divided into four groups by age. Then, 4 matched control groups of patients who had hip osteoarthritis (OA) were created. Multivariate logistic regression analyses were used to evaluate the rates of medical and surgical complications. Additionally, cohorts with a minimum 5-year follow-up were filtered to obtain further data on surgical outcomes. The study analyzed 85,462 non-traumatic ONFH and 80,120 hip OA patients undergoing THA., Results: Multiple medical complications in ONFH patients increased with age. Periprosthetic fracture within 2 years increased with age, while 90-day wound complications, 2-year periprosthetic joint infections, dislocations, and revisions decreased. The trends for complications continued at the 5-year follow-up. Compared to OA patients, those who had ONFH had higher risks of most complications, but this discrepancy decreased with age., Conclusions: In ONFH patients undergoing THA, medical complications generally rise with age, while most surgical complications, including revisions, decrease. It is notable that ONFH patients experienced more complications than those who had OA, but this difference diminished with age., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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., (© 2024. The Author(s).)

Introduction: Despite the recent increase in the use of cephalomedullary nails for trochanteric hip fractures, factors that may be associated with peri‑implant femoral fracture (PIFF) after cephalomedullary nailing for trochanteric fractures remain unknown. We investigated the factors associated with PIFF after cephalomedullary nailing of trochanteric hip fractures in older patients., Methods: A nested case-control study was conducted using a database of patients aged ≥65 years who underwent surgery with cephalomedullary nails for trochanteric fractures caused by low-energy trauma during 2005-2021. The cases were defined as patients who developed PIFF after surgery, while controls were patients who did not develop PIFF and who were followed up for ≥3 years after surgery. Four controls were randomly matched to each case for sex and age. First, potential factors associated with PIFF were compared between cases and controls. Second, multivariable conditional logistic regression analysis was employed to assess factors possibly associated with PIFF, controlling for potential confounding factors., Results: Of 1531 patients who underwent surgery with cephalomedullary nails because of trochanteric fractures, we assessed 34 cases and 136 controls (N = 170; mean age 85.7 ± 7 years; and females, 94 %). PIFF was significantly associated with patients having undergone total knee arthroplasty (adjusted odds ratios [95 % confidence intervals], 4.41 [1.16-16.8]) and those with AO/OTA classification 31A3 fracture (A3 fracture) (2.3 [1.12-4.76]), after adjusting for potential confounding factors., Conclusions: Our results showed that PIFF was more likely to develop among older patients with a clinical history of total knee arthroplasty and A3 fracture. These findings suggest that such patients may require careful follow-up with rigorous assessments after cephalomedullary nailing for trochanteric fractures., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Introduction: The incidence of periprosthetic distal femur fractures (PDFF) is increasing as the number of total knee replacements becomes more common. This study compared the demographics, fracture characteristics, treatment, and outcomes of periprosthetic versus native distal femur fractures (NDFF)., Materials and Methods: This was a retrospective cohort study of patients ≥ 18 who underwent surgical fixation of NDFF or PDFF from 2012 to 2020 at a level-1 trauma center. The main variables collected included demographics, AO/OTA fracture classification, fixation construct, concomitant fractures, polytrauma rates, bone density, and reduction quality. Primary outcomes were unexpected return to the operating room (UROR), hospital length of stay, and quality of reduction. T-tests, Fisher's exact tests, and multivariate analyses were used for statistical analysis., Results: 209 patients were identified, including 70 PDFF and 139 NDFF. PDFF patients were elderly females (81%) with isolated (80%) and comminuted (85%) 33 A.3 (71%) fractures. NDFF patients included 53% females, were commonly middle-aged, and displayed comminuted (92%) 33 C.2 fractures. 48% of NDFF patients had concomitant fractures. Intramedullary nailing was the primary fixation for both groups, followed by nail-plate combination (37%) for PDFF and lateral locking plates (21%) for NDFF. NDFF patients experienced significantly longer hospital stays, higher UROR rates, and worse quality of reduction (p < 0.05). PDFF patients had a significantly greater prevalence of low bone density (p < 0.05)., Conclusion: PDFF occur as isolated injuries with significant metaphyseal comminution in elderly females with low bone quality. NDFF commonly occurs in younger patients with less metaphyseal comminution and concomitant fractures. Intramedullary nailing was the most common treatment for both groups, although preference for nail-plate combination fixation is increasing. NDFF type 33 C fractures are at greater risk of UROR., (© 2024. The Author(s).)

Purpose: After cemented total hip arthroplasty, the risk of periprosthetic fracture (PPF) of taper-slip stems is higher than that of composite-beam stems. We aimed to assess the conditions resulting in PPFs of taper-slip stems using a falling weight., Methods: Taper-slip stems were fixed to five types of simulated bone models using bone cement, and the fractures were evaluated by dropping stainless-steel weights from a predetermined height onto the heads. The periprosthetic fracture height in 50% of the bone models (PPFH 50 ) was calculated using the staircase method., Results: For the fixation with 0° of flexion, the values for PPFH 50 were 61 ± 11, 60 ± 13, above 110, 108 ± 49, and 78 ± 12 cm for the cobalt-chromium-molybdenum alloy, stainless steel alloy (SUS), titanium alloy (Ti), smooth surface, and thick cement mantle models, respectively; for the fixation with 10° of flexion (considering flexure), the PPFH 50 values were 77 ± 5, 85 ± 9, 90 ± 2, 89 ± 5, and 81 ± 11 cm, respectively. The fracture rates of the polished-surface stems were 78.6 and 35.7% at the proximal and distal sites, respectively (p < 0.05); the fracture rates of the smooth-surface stems were 14.2 and 100%, respectively (p < 0.05)., Conclusion: The impact tests demonstrated that the conditions that were less likely to cause PPFs were use of Ti, a smooth surface, a thick cement mantle, and probably, use of SUS., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Background: In osteoporotic patients, surgeons may utilize cemented femoral fixation to minimize risk of fracture. The purpose of this study was to compare 5-year implant survivability in patients who have osteoporosis who underwent elective total hip arthroplasty (THA) with cementless versus cemented fixation., Methods: A retrospective analysis of patients who have osteoporosis undergoing THA with either cemented or cementless femoral fixation was conducted using a national administrative claims database. Of the 18,431 identified THA patients who have osteoporosis, 15,867 (86.1%) underwent cementless fixation. The primary outcome was a comparison of the 5-year cumulative incidences of aseptic revision, mechanical loosening, and periprosthetic fracture (PPF). Kaplan-Meier and Multivariable Cox Proportional Hazard Ratio analyses were used, controlling for femoral fixation method, age, sex, a comorbidity scale, use of osteoporosis medication, and important comorbidity., Results: There was no difference in aseptic revision (Hazard's Ratio (HR): 1.13; 95% Confidence Interval (CI): 0.79 to 1.62; P value: .500) and PPF (HR: 0.96; 95% CI: 0.64 to 1.44; P value: .858) within 5 years of THA between fixation cohorts. However, patients who had cemented fixation were more likely to suffer mechanical loosening with 5 years post-THA (HR: 1.79; 95% CI: 1.17 to 2.71; P-value: .007)., Conclusions: We found a similar 5-year rate of PPF when comparing patients who underwent cementless versus cemented femoral fixation for elective THA regardless of preoperative diagnosis of osteoporosis. While existing registry data support the use of cemented fixation in elderly patients, a more thorough understanding of the interplay between age, osteoporosis, and implant design is needed to delineate in whom cemented fixation is most warranted for PPF prevention., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Of children, 30% to 35% with cerebral palsy (CP) develop hip subluxation or dislocation and often require reconstructive hip surgery, including varus derotation osteotomy (VDRO). A recent literature review identified postoperative fractures as the most common complication (9.4%) of VDROs. This study aimed to assess risk factors for periprosthetic fracture after VDRO in children with CP., Methods: A total of 347 patients (644 hips, 526 bilateral hips) with CP and hip subluxation or dislocation (129 females; mean age at index VDRO: 8.6 y, SD 3.4, range: 1.5 to 17.7; 2 Gross Motor Function Classification System (GMFCS) I, 35 GMFCS II, 39 GMFCS III, 119 GMFCS IV, 133 GMFCS V, 21 unavailable) were included in this retrospective, single-group intervention (VDRO) study at a tertiary referral center. Imaging and clinical documentation for patients age 18 years or younger at index surgery, treated with VDRO were reviewed to determine demographic data, GMFCS level, surgeon, type of hardware implanted, use of anticonvulsants and steroids, type of postoperative immobilization, presence of periprosthetic fractures, fracture location and mechanism, and time from surgery to fracture. Potential determinants of periprosthetic fractures were assessed using mixed effects logistic regression., Results: Of 644 hips, 14 (2.2%, 95% CI: 1.3%, 3.6%) sustained a periprosthetic fracture, at a median of 2.1 years postoperatively (interquartile range: 4.6 y, range: 1.2 mo to 7.8 y). Patients with a fracture had a median age at index surgery of 7.3 years (interquartile range: 4.3, range: 2.8 to 17.8; 1 GMFCS II, 6 GMFCS IV, 7 GMFCS V). Periprosthetic fractures were not significantly related to age at index surgery ( P = 0.18), sex ( P = 0.30), body mass index percentile ( P = 0.87), surgery side ( P = 0.16), anticonvulsant use ( P = 0.35), type of postoperative immobilization ( P = 0.40), GMFCS level ( P = 0.31), or blade plate size ( P = 0.17). Only surgeon volume significantly related to periprosthetic fracture (odds ratio = 5.03, 95% CI: 1.53, 16.56, P = 0.008), with the highest-volume surgeon also using smaller blade plates ( P < 0.01)., Conclusions: Periprosthetic fractures after VDRO surgery in children with CP are uncommon, and routine hardware removal appears unnecessary. The data suggest that the common dogma of putting in the largest blade plate possible to maximize fixation may increase the risk of periprosthetic fracture. Due to the overall low fracture rate, especially when contextualized relative to the risk of hardware removal, a reactive approach to hardware removal appears warranted., Level of Evidence: Level III-retrospective study (targeting varus derotational osteotomies in children with cerebral palsy)., Competing Interests: S.P.W. is a stockholder (within the last 2 years) for Johnson & Johnson. The remaining authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Increasing the stem size during surgery is associated with a higher incidence of intraoperative periprosthetic fractures in cementless total hip arthroplasty with fully coated tapered wedge stems, especially in femurs of Dorr type A. If in contrast a stem is implanted and sufficient primary stability is not achieved, such preventing successful osseointegration due to increased micromotions, it may also fail, especially if the stem is undersized. Stem loosening or periprosthetic fractures due to stem subsidence can be the consequence. The adaptation of an established stem design to femurs of Dorr type A by design modifications, which increase the stem width proximally combined with a smaller stem tip and an overall shorter stem, might reduce the risk of distal locking of a proximally inadequately fixed stem and provide increased stability. The aim of this study was to investigate whether such a modified stem design provides improved primary stability without increasing the periprosthetic fracture risk compared to the established stem design. The established (Corail, DePuy Synthes, Warsaw, IN, US) and modified stem designs (Emphasys, DePuy Synthes, Warsaw, IN, US) were implanted in cadaveric femur pairs (n = 6 pairs) using the respective instruments. Broaching and implantation forces were recorded and the contact areas between the prepared cavity and the stem determined. Implanted stems were subjected to two different cyclic loading conditions according to ISO 7206-4 using a material testing machine (1 Hz, 600 cycles @ 80 to 800 N, 600 cycles @ 80 to 1600 N). Translational and rotational relative motions between stem and femur were recorded using digital image correlation. Broaching and implantation forces for the modified stem were up to 40% higher (p = 0.024), achieving a 23% larger contact area between stem and bone (R2 = 0.694, p = 0.039) resulting in a four times lower subsidence during loading (p = 0.028). The slight design modifications showed the desired effect in this in-vitro study resulting in a higher primary stability suggesting a reduced risk of loosening. The higher forces required during the preparation of the cavity with the new broaches and during implantation of the stem could bare an increased risk for intraoperative periprosthetic fractures, which did not occur in this study., Competing Interests: MMM is a paid consultant of DePuy Synthes and obtains research support as a Principal Investigator from Ceramtec, DePuy, and Beiersdorf. He obtains speaker’s fees from Aesculap, Ceramtec, DePuy, Zimmer, Peter Brehm, Corin, and Mathys andis in the editorial board “Trauma und Berufskrankheit.” GH is an associated member of the board of the German Society of Biomechanics. F. L. is a paid consultant of Depuy Synthes and Aesculap. B. O. is a board member of the German Society of Legal Medicine., (Copyright: © 2024 Glismann et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Periprosthetic femur fracture (PFF) following total hip arthroplasty (THA) is a leading cause of early reoperation. The objective of this study was to compare rates of periprosthetic joint infection (PJI) and reoperation following PFFs occurring early postoperatively to those that occurred late., Methods: We retrospectively identified 173 consecutive surgically managed PFFs following primary THA. Cases were categorized as "early" if they occurred within 90 days of THA (n = 117) or "late" if they occurred following the initial 90 days (n = 56). Mean age at time of PFF was 68 years (range, 26 to 96) and 60% were women. Mean body mass index was 29 (range, 16 to 52). Mean follow-up was 2 years (range, 0 to 13). Kaplan-Meier survival analysis estimated cumulative incidences of PJI and reoperation., Results: Early PFFs had higher 2-year cumulative incidence of PJI (11% versus 0%, P < .001) and reoperation (24% versus 13%, P = .110). Following early PFF, 27 patients required reoperation (ie, 13 for PJI, 5 for instability, 2 for re-fracture, 2 for painful hardware, 2 for non-union, 1 for adverse local tissue reaction, 1 for aseptic loosening, and 1 for leg-length discrepancy). Following late PFF, 5 patients required reoperation (ie, 3 for instability, 1 for re-fracture, and 1 for non-union)., Conclusions: There are greater incidences of PJIs and overall reoperations following early PFFs compared to late PFFs after THA. In addition to focusing efforts on prevention of early PFFs, surgeons should consider antiseptic interventions to mitigate the increased risk of PJI after treatment of early PFF., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Periprosthetic fractures (PPFs) account for approximately 25% of early revisions following total hip arthroplasty (THA). Cemented femoral fixation is associated with a lower-risk of PPF, and collared-cementless stems may reduce the risk as well. The objective of this study was to compare early-PPF rates between cemented, collared-cementless, and non-collared cementless stems in elderly patients., Methods: A consecutieve-series of 11,522 primary THAs performed between 2016 and 2021 at our institution in patients >65 years of age was identified. Stem types used were categorized as cemented, collared-cementless, or non-collared cementless. Patients undergoing THA who had cemented-stems were older, more commonly women, and more likely to have a posterior-approach. To reduce confounding of patient characteristics, we matched patients in the 3 stem-categories according to age, sex, and body mass index. This generated 3-groups (cemented, collared-cementless, and non-collared cementless) consisting of 936 patients per group. The mean age of these 2,808 patients was 73 years, the mean body mass index was 27, and 67% were women. Logistic regressions were used to evaluate risk-factors for early-PPF. In the entire cohort of primary THA in elderly patients, there were 85 early PPFs (0.7%) over the study period., Results: Non-collared cementless stems were associated with an increased risk of early PPF (OR: 3.11; P = .03) compared to collared-cementless stems. There were no early PPFs in the matched cemented cohort, 6 early PPFs in the matched collared-cementless cohort, and 16 early-PPFs in the matched non-collared cementless cohort (0% versus 0.64% versus 1.71%, P < .001)., Conclusions: In this large-series of patients >65 years of age undergoing primary THA, cemented stem fixation had the lowest incidence of early PPF, but collared-cementless stems had a nearly 3-fold decrease in risk for early PPF compared to non-collared cementless stems., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: While robotic-arm assisted total knee arthroplasty (RA-TKA) has seen a major increase in its utilization, it requires bone array pins to be fixed into the femur and tibia, which intrinsically carries a risk. As it is currently off-label with some robotic platforms to place pins intraincisional, we aimed to evaluate the safety of intraincisional pin placement during RA-TKAs., Methods: A prospective cohort of 2,343 patients who underwent RA-TKA at a North American Healthcare System between January 2018 and March 2022 was included. Primary outcomes included periprosthetic fracture or infection (eg, superficial or deep). Secondary outcomes included 1-year reoperation rate due to any cause. Cases were retrospectively reviewed to determine whether complications could be attributed to metaphyseal intraincisional pin placement (4.0 mm pins; two tibial and two femoral). The 90-day follow-up was 100% and the 1-year follow-up rate was 70.6% (n = 1,655)., Results: The pin-site related periprosthetic fracture incidence at 90 days was 0.09% (2 out of 2,343). The 90-day infection incidence was 1.4% (superficial: 22; deep: 13). The 1-year reoperation rate was 1.8% (29 out of 1,655). The most common causes of reoperation at 1-year were deep infection (n = 14; 0.83%), superficial infection (n = 3; 0.18%), periprosthetic fracture, mechanical symptoms, instability, and hematoma (n = 2; 0.12% for each)., Conclusions: One in 1,172 patients may experience a pin-related periprosthetic fracture after RA-TKA with intraincisional bone array pin placement. There was a low 90-day infection incidence and reoperations within 1-year after RA-TKA were rare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The risk of revision surgery in patients who have osteoporosis after total knee arthroplasty (TKA) is understudied. Our aim was to compare the 5-year cumulative risk of revision surgery after TKA in patients who have preoperative osteoporosis., Methods: A national administrative claims database was queried for patients undergoing primary TKA from 2010 to 2021. There were 418,054 patients included, and 41,760 (10%) had osteoporosis. The 5-year incidence of revision surgery was examined for all-causes, periprosthetic fracture (PPF), aseptic loosening, and periprosthetic joint infection (PJI). A multivariable analysis was conducted using Cox proportional hazards models. Hazards ratios (HRs) were reported with 95% confidence intervals (CIs)., Results: The 5-year rate of all-cause revision surgery was higher for patients who had osteoporosis (HR 1.1, 95% CI: 1.0 to 1.2), however, the highest risk of revision surgery was seen for PPF (HR 1.8, 95% CI: 1.6 to 2.1). Patients who had osteoporosis also had elevated risk of revision surgery for PJI (HR 1.2, 95% CI: 1.1 to 1.3) and aseptic loosening (HR 1.2, 95% CI: 1.1 to 1.3). Osteoporosis was independently associated with PJI and aseptic loosening at a higher rate in obese patients., Conclusions: In unadjusted survival analysis, those who had osteoporosis have a marginally lower risk of all-cause revision surgery. However, after controlling for age, sex and comorbidities, patients who had osteoporosis have a nearly 2-fold increased risk of 5-year revision for PPF after TKA, and mildly increased risk of revision for all causes, aseptic loosening, and PJI. Obesity may also modulate this association. Future studies should determine the extent to which treatment of osteoporosis modifies these postoperative outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The incidence of all periprosthetic fractures (PPF), which require complex surgical treatment associated with high morbidity and mortality, is predicted to increase. The evolving surgical management has created a knowledge gap regarding its impact on immediate outcomes. This study aimed to describe current management strategies for PPF and their repercussions for in-hospital outcomes as well as to evaluate their implications for the community., Methods: PIPPAS (Peri-Implant PeriProsthetic Survival Analysis) was a prospective multicentre observational study of 1387 PPF performed during 2021. Descriptive statistics summarized the epidemiology, fracture characteristics, management, and immediate outcomes. A mixed-effects logistic regression model was employed to evaluate potential predictors of in-hospital mortality, complications, discharge status, and weight-bearing restrictions., Results: The study encompassed 32 (2.3%) shoulder, 4 (0.3%) elbow, 751 (54.1%) hip, 590 (42.5%) knee, and 10 (0.7%) ankle PPF. Patients were older (median 84 years, IQR 77-89), frail [median clinical frailty scale (CFS) 5, IQR 3-6], presented at least one comorbidity [median Charlson comorbidity index (CCI) 5, IQR 4-7], were community dwelling (81.8%), and had outdoor ambulation ability (65.6%). Femoral knee PPF were most frequently associated with uncemented femoral components, while femoral hip PPF occurred equally in cemented and uncemented stems. Patients were managed surgically (82%), with co-management (73.9%), through open approaches (85.9%) after almost 4 days (IQR, 51.9-153.6 h), with prosthesis revision performed in 33.8% of femoral hip PPF and 6.5% of femoral knee PPF. For half of the patients, the discharge instructions mandated weight-bearing restrictions. In-hospital mortality rates were 5.2% for all PPF and 6.2% for femoral hip PPF. Frailty, age > 84 years, mild cognitive impairment, CFS > 3, CCI > 3, and non-geriatric involvement were candidate predictors for in-hospital mortality, medical complications, and discharge to a nursing care facility. Management involving revision arthroplasty by experienced surgeons favoured full weight-bearing, while an open surgical approach favoured weight-bearing restrictions., Conclusions: Current arthroplasty fixation check and revision rates deviate from established guidelines, yet full weight-bearing is favoured. A surgical delay of over 100 h and a lack of geriatric co-management were related to in-hospital mortality and medical complications. This study recommends judicious hypoaggressive approaches. Addressing complications and individualizing the surgical strategy can lead to enhanced functional outcomes, alleviating the economic and social burdens upon hospital discharge. Level of Evidence Level IV case series., Trial Registration: registered at ClinicalTrials.gov (NCT04663893), protocol ID: PI 20-2041., (© 2024. The Author(s).)

Introduction: Disproportionate emphasis has been attributed to hip fracture over other femoral fractures through implementation of Best Practice Tariff (BPT).This retrospective comparative observational cohort study aimed to evaluate the epidemiology of native and periprosthetic femoral fractures and establish any disparities in their management relative to hip fractures., Methods: All patients ⩾60 years admitted with a native or periprosthetic femoral fracture during July 2016-June 2018 were identified using our hospital database. Results were compared to National Hip Fracture Database data over the same period., Results: 58 native femoral, 87 periprosthetic and 1032 hip fractures were identified. (46/58) 79% and 76/87 (89%) of native and periprosthetic femoral fractures were managed operatively. Surgery was performed <36 hours for 34/46 (74%) of native femoral and 33/76 (43%) of periprosthetic fractures compared to 826/1032 (80%) for hips. Median time to surgery was longer in periprosthetic femoral than hip fracture patients (44.7 vs. 21.6 hours; p   <  0.0001). Orthogeriatrician review occurred in 24/58 (41%) and 48/87 (55%) of native and periprosthetic fractures compared to 1017/1032 (99%) for hips ( p   <  0.0001). One year mortality was 35%, 20% and 26% for native femoral, periprosthetic and hip fracture patients. Cox proportional hazard ratio was higher for native femoral than hip fracture patients (1.75; 95% CI, 1.12-2.73)., Conclusions: This study demonstrates large disparities in management of other femoral and periprosthetic fractures compared to hip fractures, specifically time to surgery and orthogeriatrician review. This may have resulted in the comparatively higher mortality rate of native femoral fracture patients. Expansion of the BPT to include the whole femur is likely to improve outcomes., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Cementless hip stems are widely used for total hip arthroplasty (THA) and have demonstrated excellent survivorship. This study aimed to investigate the effects of stem size and calcar collars on rates of revision due to periprosthetic fracture., Methods: All primary THA procedures recorded by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from September 1999 to December 2021 for a diagnosis of osteoarthritis using a single cementless hip stem with modern bearings were included. The primary outcome measure was revision due to periprosthetic fracture. Stems were divided into 2 groups for comparison, large (size 14 to 20) and small-medium (6 to 13). A subanalysis was performed for collared stems. A total of 59,518 primary THA procedures were included., Results: The cumulative percent revision for periprosthetic fracture was significantly higher for large stems compared to small-medium stems (hazard ratio [HR] = 1.57 [95% confidence interval {CI} 1.18, 2.09] P = .002). Furthermore, collared stems had significantly lower revision rates due to late periprosthetic fracture compared to collarless variants (2 week + HR = 4.55 [95% CI 3.23, 6.42], P < .001). Large collarless stems were found to have greater revision rates due to fracture compared to small-medium collarless stems (HR = 1.55 [95% CI 1.13, 2.12] P = .006), but no difference was found between collared groups (HR = 1.37 [95% CI 0.68, 2.78] P = .382)., Conclusion: Large cementless hip stems have a higher rate of revision due to periprosthetic fracture compared to small-medium stems. Using a collared stem reduces the rate of periprosthetic fracture., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)