BACKGROUND: There have been several studies on intraoperative femoral fractures (IFFs) during primary total hip arthroplasty, but it is not well understood how this complication affects the patient population undergoing cemented hemiarthroplasty. This study aimed to analyze the impact of IFFs sustained during cemented hemiarthroplasty for the treatment of femoral neck fractures.
METHODS: A retrospective review was conducted of all patients who were treated for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 31B fractures with cemented hemiarthroplasty between January 1, 2000, and December 31, 2021, at a single academic Level 1 trauma center. An initial cohort was constructed of all patients who sustained an IFF during their surgery, yielding 31 patients after excluding those who sustained a pathologic fracture or had incomplete data. These patients were matched 1:2 on age, sex, and body mass index (BMI) to patients in a control cohort. The primary outcome measure was implant failure. Secondary outcome measures included complications, all-cause mortality, and radiographic outcomes (subsidence, femoral component loosening, acetabular wear, and heterotopic ossification) postoperatively.
RESULTS: Subsequent implant revision was required in 3.2% (n = 1) of patients who sustained an IFF and 1.6% (n = 1) of patients who did not. After adjusting for comorbidities, there was no observed excess risk of implant failure in the fracture cohort when compared to the control cohort (hazard ratio [HR] = 0.30, P = 0.740). There was no observed excess risk of morbidity (HR = 0.69, P = 0.621) or all-cause mortality (HR = 0.23, P = 0.330). Radiographic outcomes also did not significantly differ between the two cohorts (P > 0.05).
CONCLUSIONS: Intraoperative fractures during cemented hemiarthroplasty do not contribute to an increased risk of secondary surgery, morbidity, or mortality after surgery. They also do not adversely affect radiographic outcomes postoperatively.

BACKGROUND: 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.
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.

BACKGROUND: Vancouver B2 and B3 periprosthetic fractures (PFF) are associated with stem instability and often require a demanding stem implant revision (SR) or internal fixation (ORIF). This latter surgery is increasingly performed in the last few years instead of SR, but it is unclear which is the best treatment to manage PFF patients. The aim of this study is the compare the outcomes of B2/B3 PFF managed by either ORIF or SR, by performing a systematic review and meta-analysis of current literature.
METHODS: Cochrane Database, PubMed, Google Scholar and MEDLINE were examined to find out relevant publications dealing with the different outcomes of SR vs. ORIF in B2/B3 PFF of the hip. The effect model (EM) was calculated using Cohen´s d index.
RESULTS: Fifteen studies were included, reporting on a total of 1629 patients (564 ORIF and 1065 SR). The pooled random EM estimates for reoperation was 0.87 (95% CI, 0.39-1.96; I2 = 78%) in favor of ORIF surgery; EM for complications was 1.01 (95% CI, 0.45-2.27; I2 = 85%) without difference among procedures. The EM for transfusion was 0.72 (95% CI, 0.46-1.12; I2 = 62%) in favor of fixation.
CONCLUSIONS: ORIF and SR were both suitable and effective options in PFF patients, being associated to similar complications rates. Our results show that ORIF performance in PFF patients is associated to significantly less in blood loss, surgical time and in-hospital stay. These advantages are particularly appealing in patients with multiple comorbidities.

Improper osteotomy during total knee arthroplasty (TKA) can lead to anterior femoral notching, which increases the risk of periprosthetic fractures due to stress concentration. One potential solution is the addition of an intramedullary stem to the femoral component. However, the optimal stem length remains unclear. In this study, we aimed to determine the optimal stem length using finite element models. Finite element models of femurs were developed with unstemmed prostheses and prostheses with stem lengths of 50, 75, and 100 mm. Under squat loading conditions, the von Mises stress at the notch and stress distribution on four transversal sections of the femur were analyzed. Additionally, micromotion of the prosthesis-bone interface was evaluated to assess initial stability. The unstemmed prosthesis exhibited a von Mises stress of 191.8 MPa at the notch, which decreased to 43.1, 8.8, and 23.5 MPa for stem lengths of 50, 75, and 100 mm, respectively. The stress reduction on four selected femoral transversal sections compared with the unstemmed prosthesis was 40.0%, 84.4%, and 67.1% for stem lengths of 50, 75, and 100 mm, respectively. Micromotion analysis showed a maximum of 118.8 μm for the unstemmed prosthesis, which decreased significantly with the application of stems, particularly at the anterior flange. Intramedullary stems effectively reduced stress concentration at the femoral notch. The 50-mm stem length provided the optimal combination of reduced notch stress, minimized stress-shielding effect, and decreased micromotion at the anterior flange.

OBJECTIVE: Periprosthetic femur fractures after total knee arthroplasty in older adults are mostly treated by internal fixation. Members of the GETRAUM (French Orthopedic Trauma Society) sought to compare two surgical techniques - conventional open surgery and minimally invasive surgery - with the aim of analyzing the patients\' functional recovery. We hypothesized that a minimally invasive technique would produce better early functional outcomes with recovery of independence.
METHODS: This retrospective multicenter study of patients treated between 2009 and 2015 consisted of 90 fractures with a follow-up of 1 year. Demographic, preoperative data and the characteristics of fractures, type of fixation and the surgeon\'s experience level were collected. The endpoints were the Parker Mobility score, Katz ADL, place of residence at the time of fracture and at 6 months and one-year follow-up. All complications and one-year mortality during the follow up were searched.
RESULTS: At 6 months follow-up, the minimally invasive technique contributed to significantly better functional recovery as measured by the Parker (p < 0.05) and Katz scores (p < 0.05). However, there were no differences in these scores at one-year follow-up. The complication rate was 31% at one year follow-up. Mortality rate was 12 % (11 patients).
CONCLUSIONS: Our hypothesis was confirmed, as there was a difference between techniques that impacted functional recovery and independence, but only in the early postoperative phase. A minimally invasive technique appears to be beneficial in the short term for distal femur fractures after total knee arthroplasty but must be evaluated in a comparative and prospective study to fully confirm its reliability.

OBJECTIVE: The incidence of periprosthetic fractures after total hip arthroplasty using a short tapered-wedge stem is high. Callus formation preceding this fracture, which indicates postoperative stress fracture around the stem, has been reported. However, previous studies on postoperative callus are limited. Hence, the current study aimed to evaluate the prevalence and risk factors of postoperative callus after total hip arthroplasty with a short tapered-wedge stem.
METHODS: This retrospective study included 127 patients who underwent total hip arthroplasty using a cementless short tapered-wedge stem. The depth of stem insertion was measured as the distance from the lateral corner of the stem to the most medial point of the lesser trochanter along the body axis. Postoperative callus was defined as a bridging callus on the lateral femoral cortex at the distal end of the porous coating of the stem. Plain radiography was performed before surgery and immediately and at 1, 3, and 6 months after surgery to assess postoperative callus. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for PC.
RESULTS: In total, 60 (47.2%) of 127 patients presented with postoperative callus. Multivariate logistic regression analysis with postoperative callus as the dependent variable revealed that the stem depth at 1 month after total hip arthroplasty (odds ratio, 1.14; 95% confidence interval, 1.04-1.24, p = 0.002) was a significant and independent risk factor of postoperative callus.
CONCLUSIONS: Deep insertion of a short tapered-wedge stem is a risk factor for postoperative callus.

OBJECTIVE: Modular cementless knee arthroplasty systems are capable of precise reconstruction of the mechanical axis. However, they are considered more susceptible to complications. In contrast, non-modular cemented systems are said to be more forgiving and show good long-term results. The aim of this study was to investigate the resulting leg axis after implantation of a non-modular cemented rotating hinged knee prosthesis. Furthermore, potential risk factors for the occurrence of malalignment and complications should be identified.
METHODS: Between 2005 and 2015, 115 patients could be included in this monocentric retrospective cohort study. All patients underwent primary hinged non-modular cemented total knee arthroplasty. Preoperative and postoperative standardized long radiographs were analysed to determine resulting leg axis. Furthermore, epidemiological and intraoperative data as well as perioperative complications were surveyed.
RESULTS: Average leg axis was 5.8° varus preoperatively and 0.6° valgus postoperatively. Considering an axis deviation of 3° as the target corridor, 27% of all cases examined were outside the desired range. 21% cases showed a femoral deviation from the target corridor and 15% showed a tibial deviation. There was a significant relationship between the preoperative mLDFA and the mechanical alignment of the femoral component (R = 0.396, p < 0.001) as well as between the preoperative mMPTA and the mechanical alignment of the tibial component (R = 0.187, p = 0.045). The mean operative duration was 96 min. No periprosthetic fractures were observed within the study cohort.
CONCLUSIONS: The main result of the present work is that a non-modular cemented rotating hinged knee arthroplasty system can reconstruct the mechanical leg axis precisely and comparable to modular cementless and unconstrained total knee prostheses. Component malalignment is primarily dependent upon extraarticular deformity preoperatively. Periprosthetic fracture rates and duration of surgery were lower compared with current literature.
METHODS: Level III: Retrospective cohort study.

UNASSIGNED: Management of periprosthetic fractures has been guided by the Vancouver classification, which recommends revision for fractures around a loose femoral implant (B2). New studies have challenged this approach, demonstrating acceptable outcomes with internal fixation. This study evaluates our experience with Vancouver B2 fractures, comparing internal fixation to femoral revision. We hypothesized that in select cases with cementless stems, internal fixation would provide acceptable results with reduced morbidity.
UNASSIGNED: A retrospective review was performed of periprosthetic hip fractures treated at our institution between 1 January 2012 and 4 November 2022. We excluded patients who did not have prior radiographs and evidence of stem subsidence, suggestive of a Vancouver B2 fracture. Thirteen patients were included in the analysis.
UNASSIGNED: Four patients (31%) underwent revision of the femoral component, 4 patients (31%) underwent plating, and 5 patients (38%) underwent internal fixation with cerclage cabling. The average operative duration was 158 minutes, 203 minutes, and 62 minutes for the revision, plating, and cabling cohorts, respectively (P = .009). Blood loss was 463 cc, 510 cc, and 90 cc for the revision, plating, and cabling cohorts, respectively (P = .036). Three patients in both the revision and plating cohorts each received a transfusion (75%), whereas no patients in the cabling cohort required a transfusion (P = .033). All patients demonstrated fracture healing on the postoperative radiographs. No patients required additional surgery during the follow-up period.
UNASSIGNED: We have demonstrated that Vancouver B2 periprosthetic fractures with intact lateral cortices may be treated with internal fixation with cerclage cabling with excellent results.

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.

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.
METHODS: Level III; Retrospective Cohort Study.