Non-operative management of humeral periprosthetic fracture after stemless shoulder arthroplasty.

PURPOSE: Periprosthetic fractures around a stemless implant often involve lesser and greater tuberosities with a well-fixed implant in the metaphysis. This exposes the surgeon to unique questions and challenges as no surgical option (open reduction and internal fixation or revision to a stem) appears satisfactory to address them. Purpose of this study was to evaluate the clinical outcomes after non-operative management of periprosthetic fractures after stemless shoulder arthroplasty. METHODS: A retrospective multicenter study was conducted to identify all patients who had sustained non-operative management of a periprosthetic fracture after a stemless shoulder. Exclusion criteria were as follows: (1) intraoperative fractures and (2) implant loosening. Primary outcomes included mean Constant score and mean active range of motion. Secondary outcomes were VAS, radiological analysis, and complications. RESULTS: Nine patients were included. One was excluded due to the loss of follow-up at three months. Mean age was 79 years. At the last follow-up, no significant difference was observed between the Constant score, VAS, or the range of motion before fracture and at the last follow-up. Fracture healing did not result in any change in angulation in the frontal plane in seven cases and was responsible for a varus malunion in two cases of anatomic arthroplasty. No change in lateralization or distalization was reported. No cases of implant loosening after fracture have been observed. CONCLUSIONS: Conservative management seems to be appropriate in cases of minimally displaced fractures without implant loosening.

Periprosthetic Infection in the Setting of Periprosthetic Total Hip Fractures: Evaluation and Management.

The incidences of periprosthetic fracture and periprosthetic joint infection after total hip arthroplasty are expected to increase exponentially over the coming decades. Epidemiologic data suggest that many periprosthetic fractures after THA occur concurrently with a loose femoral implant. Recent studies suggest an approximately 8% incidence of indolent infection in cases of suspected aseptic loosening. The available data, therefore, suggest that periprosthetic fracture and infection may coexist, and this possibility should be considered, particularly in patients with a loose femoral stem and high pretest possibility. Although currently limited, the available literature provides some guidance as how to manage this complex issue.

Classification and Management of Periprosthetic Patella Fractures.

Complications related to the extensor mechanism and patellofemoral joint continue to be the most common cause of pain and indication for surgical revision following total knee arthroplasty. Numerous risk factors related to the patient, implant, and technical performance of the procedure have been identified. The Ortiguera and Berry classification system is widely used for the systematic classification and management of these fractures. Because of the difficult nature of revision surgery for fracture and the high risk of complication, a careful assessment of the fracture and implants is vital to determining the best course of treatment.

A Review of Periprosthetic Tibial Fractures: Diagnosis and Treatment.

Periprosthetic fracture occurring during or after total knee arthroplasty is a rare injury. Literature concerning periprosthetic tibial factures is sparse, and there is limited guidance for evidence-based management. This review aims to provide readers with an overview of the epidemiology, risk factors, and classification of these fractures. Management includes nonoperative treatment of nondisplaced fractures, fixation for those with stable implants, and revision for those with loose implants.

Do standards of care and early outcomes of periprosthetic fractures change during the COVID-19 pandemic? A multicentre study.

BACKGROUND: Periprosthetic fractures (PPFs) are a growing matter for orthopaedic surgeons, and patients with PPFs may represent a frail target in the case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The purpose of this study is to investigate whether hospital reorganisations during the most severe phase of the SARS-CoV-2 pandemic affected standards of care and early outcomes of patients treated for PPFs in Northern Italy. MATERIALS AND METHODS: Data were retrieved from a multicentre retrospective orthopaedics and traumatology database, including 14 hospitals. The following parameters were studied: demographics, results of nasopharyngeal swabs, prevalence of coronavirus disease 2019 (COVID-19), comorbidities, general health status (EQ-5D-5L Score), frailty (Clinical Frailty Scale, CFS), pain (visual analogue scale, VAS), anaesthesiologic risk (American Society of Anaesthesiology Score, ASA Score), classification (unified classification system, UCS), type of operation and anaesthesia, in-hospital and early complications (Clavien-Dindo Classification, CDC), and length of stay (LOS). Data were analysed by means of descriptive statistics. Out of 1390 patients treated for any reason, 38 PPFs were included. RESULTS: Median age was 81 years (range 70-96 years). Twenty-three patients (60.5%) were swabbed on admission, and two of them (5.3%) tested positive; in three patients (7.9%), the diagnosis of COVID-19 was established on a clinical and radiological basis. Two more patients tested positive post-operatively, and one of them died due to COVID-19. Thirty-three patients (86.8%) presented a proximal femoral PPF. Median ASA Score was 3 (range, 1-4), median VAS score on admission was 3 (range, 0-6), median CFS was 4 (range, 1-8), median EQ-5D-5L Score was 3 in each one of the categories (range, 1-5). Twenty-three patients (60.5%) developed post-operative complications, and median CDC grade was 3 (range, 1-5). The median LOS was 12.8 days (range 2-36 days), and 21 patients (55.3%) were discharged home. CONCLUSIONS: The incidence of PPFs did not seem to change during the lockdown. Patients were mainly elderly with comorbidities, and complications were frequently recorded post-operatively. Despite the difficult period for the healthcare system, hospitals were able to provide effective conventional surgical treatments for PPFs, which were not negatively influenced by the reorganisation. Continued efforts are required to optimise the treatment of these frail patients in the period of the pandemic, minimising the risk of contamination, and to limit the incidence of PPFs in the future. LEVEL OF EVIDENCE: IV.

Biconvex Patellar Components: 96% Durability at 10 Years in 262 Revision Total Knee Arthroplasties.

BACKGROUND: The optimal strategy to address osseous deficiencies of the patella during revision total knee arthroplasty (TKA) remains controversial. One possible solution is a cemented biconvex patellar component used such that the non-articular convexity both improves fixation and makes up for bone loss. The aim of this study was to determine the outcomes of the use of biconvex patellar components in a large series of revision TKAs. METHODS: From 1996 to 2014, 262 revision TKAs were performed at a single institution using a biconvex patellar component. Implant survivorship, clinical and radiographic results, and complications were assessed. The mean patient age at the TKA revision was 69 years, and 53% of the patients were female. The mean follow-up was 7 years. RESULTS: The 10-year survivorship free of revision of the biconvex patellar component due to aseptic loosening was 96%. The 10-year survivorship free of any revision of the biconvex patellar component was 87%. The 10-year survivorship free of any rerevision and free of any reoperation was 75% and 70%, respectively. The mean Knee Society Score (KSS) improved from 45.4 before the index revision to 67.7 after it. The mean residual composite thickness seen on the most recent radiographs was 18.1 mm. In addition to the complications leading to revision, the most common complications were periprosthetic patellar fracture (6%), of which 3 required revision; superficial wound infection (6%) requiring antibiotic therapy only or irrigation and debridement; and arthrofibrosis (3%). CONCLUSIONS: In this cohort of 262 revision TKAs, biconvex patellar components used to treat marked patellar bone loss demonstrated excellent durability with a 10-year survivorship free of patellar rerevision due to aseptic loosening of 96%. The biconvex patellar components were reliable as evidenced by substantial improvements in clinical outcomes scores and a low risk of complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Nonoperative Treatment of Periprosthetic Humeral Shaft Fractures After Reverse Total Shoulder Arthroplasty.

Few studies report on periprosthetic humeral shaft fractures after reverse total shoulder arthroplasty (RTSA). The authors evaluated outcomes of 5 patients with this complication who were initially treated nonoperatively. Of 152 patients who underwent RTSA at the authors' institution from 2012 to 2017, 4 experienced periprosthetic humeral shaft fractures. One patient was referred to the authors for fracture treatment. All 5 patients were initially treated nonoperatively. The mean duration of follow-up was 11.5 months (range, 1.5-26 months). The authors analyzed time to fracture union, Single Assessment Numeric Evaluation (SANE) score, visual analog scale (VAS) score for pain, and active shoulder range of motion. Fracture union occurred in 4 patients treated nonoperatively at a mean of 4.4 months. Mean SANE score was 55 of 100 (range, 20-85). Mean VAS score was 3.4 of 10 (range, 0-8). Mean forward elevation was 83° (range, 45°-110°); mean abduction was 65° (range, 45°-80°); and mean external rotation with the arm at the side was 15° (range, 0°-30°). Many factors must be considered when customizing treatment for patients with periprosthetic fracture after RTSA. This case series indicates that nonoperative treatment of postoperative periprosthetic humeral shaft fractures can be successful. [Orthopedics. 2020;43(6):e553-e560.].

Treatment and outcomes of Vancouver type B periprosthetic femoral fractures.

AIMS: Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF. METHODS: A total of 97 consecutive PPFs (49 males and 48 females) were included with a mean age of 66 years (standard deviation (SD) 14.9). Of these, 86 patients were treated with surgery and 11 were treated conservatively. All living patients had a minimum two-year follow-up. Patient demographics details, fracture healing, functional scores, and complications were assessed. Clinical outcomes between internal fixation and revisions in patients with or without a stable femoral component were compared. Conservatively treated PPFs were evaluated in terms of mortality and healing status. A logistic regression analysis was performed to identify risk factors for complications. RESULTS: In surgically treated patients, all fractures united and nine complications were identified. The mean postoperative Visual Analogue Scale (VAS) for pain was 1.5 (SD 1.3), mean Parker Mobility Score (PMS) was 6.5 (SD 2.4), and mean Harris Hip Score (HHS) was 79.4 (SD 16.2). Among type B2 and type B3 fractures, patients treated with internal fixation had significantly lower PMS (p = 0.032) and required a longer time to heal (p = 0.012). In conservatively treated patients, one-year mortality rate was 36.4% (4/11), and two patients ultimately progressed to surgery. Young age (p = 0.039) was found to be the only risk factor for complications. CONCLUSION: The overall clinical outcome among Vancouver type B PFF was satisfactory. However, treatment with internal fixation in type B2 and B3 fractures had a significantly longer time to heal and lower mobility than revision cases. Conservative treatment was associated with high rates of early mortality and, in survivors, nonunion. This probably reflects our selection bias in undertaking surgical intervention. In our whole cohort, younger patient age was a risk factor for postoperative complications in Vancouver type B PFF. Cite this article: Bone Joint J 2020;102-B(3):293-300.

High mortality following distal femur fractures: a cohort study including three hundred and two distal femur fractures.

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

[Conservative treatment of periprosthetic humeral fractures years after cemented fracture prostheses : A case series]. / Konservative Therapie periprothetischer Humerusfrakturen Jahre nach zementierter Frakturprothese : Eine Fallserie.

BACKGROUND: The exact incidence of postoperative periprosthetic humeral fractures (PPHF) months or years after fracture-related implantation of a hemiprosthesis is unknown. The currently available literature is predominantly concerned with operative treatment approaches. As a rule, these involved older patients and severe fracture conditions so that severe complications and unsatisfactory healing results were described. This article presents an alternative conservative treatment approach which is discussed based on the results of treatment. PATIENTS AND METHODS: Between 2011 and 2016 a conservative treatment of 5 female patients with PPHF could be carried out. Of the patients 4 were clinically and radiologically controlled at a mean follow-up time of 23 months. The fifth patient died 2 months after the trauma and only partial information of the treatment was available. RESULT: There were no intrahospital complications and just one posthospital complication. In the case of the patient who later died, repeated and unauthorized removal of the upper arm brace occurred in the nursing institution resulting in a lesion of the radial nerve. Of the four patients who completed treatment, three were very satisfied with the outcome of treatment. The mean DASH (Disabilities of Arm, Shoulder and Hand) and Oxford shoulder scores were on average 74 and 25 points, respectively. At the time of the follow-up examination all patients were free of pain, without the use of analgesics; however, there were still some limitations in the activities of daily life, which in three of the four patients was similar to the results following implantation of the fracture prosthesis. CONCLUSION: The conservative treatment of PPHF can be a safe treatment option in multimorbid and chronically ill patients. A close outpatient control and good patient compliance are important. In incompliant and dementia patients, the risk of failure of conservative treatment is increased.

Periprosthetic fractures about total knee arthroplasty.

Periprosthetic fracture after total knee arthroplasty presents a difficult complication for many orthopaedic surgeons. These fractures occur most frequently around the distal femur followed by the patella and then tibia. These fractures are frequently complicated by poor bone quality or compromised bone due to the presence of the implants. Surgical treatment is typically necessary and requires varied techniques of open fixation, intramedullary fixation, or revision arthroplasty. Outcomes of these injuries vary widely. This review aims to describe the epidemiology, classification, treatment options and outcomes for periprosthetic fractures following total knee arthroplasty.

Post-operative periprosthetic humeral fractures after reverse shoulder arthroplasty: a review of the literature.

BACKGROUND AND AIM OF THE WORK: Post-operative periprosthetic shoulder fractures incidence is gradually raising due to aging of population and increasing of reverse total shoulder arthroplasty (RTSA). Management of this complication represents a challenge for the orthopedic surgeon. Aim of the present study is to critically review the recent literature about epidemiology, risk factors, diagnosis, management and outcome of post-operative periprosthetic humeral  fractures occurring on RTSA. METHODS: A systematic search of Embase, Medline and Pubmed was performed by two reviewers who selected the eligible papers favoring studies published in the last ten years. Epidemiology, risk factors, diagnostic features, clinical management and outcome of different techniques were all reviewed. RESULTS: 31 studies including reviews, meta-analysis, case reports, clinical and biomechanical studies were selected. CONCLUSIONS: Correct clinical management requires adequate diagnosis and evaluation of risk factors. Conservative treatment is rarely indicated. Locking plate fixation and revision arthroplasty are both valuable treatment methods. Surgical technique should be chosen considering age and functional demand, comorbidities, fracture morphology and location, bone quality and stability of the implant. Given the correct indication all surgical treatment can lead to satisfactory clinical and radiographic results despite a relevant complication rate.

Denosumab-Associated Peri-Implant Atypical Femur Fracture: A Case Report.

Bisphosphonate use has been associated with atypical pathologic fracture and slowed bone turnover. We present a case of a bisphosphonate-associated peri-implant atypical femur fracture following use of a recon nail for treatment of a prior bisphosphonate-associated atypical femur fracture.

[Traumatic periprosthetic fractures in patients with total hip replacement]. / Traumatische periprothetische Frakturen bei einliegender Hüftprothese.

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

Executive Summary of the 2019 ISCD Position Development Conference on Monitoring Treatment, DXA Cross-calibration and Least Significant Change, Spinal Cord Injury, Peri-prosthetic and Orthopedic Bone Health, Transgender Medicine, and Pediatrics.

To answer important questions in the fields of monitoring with densitometry, dual-energy X-ray absorptiometry machine cross-calibration, monitoring, spinal cord injury, periprosthetic and orthopedic bone health, transgender medicine, and pediatric bone health, the International Society for Clinical Densitometry (ISCD) held a Position Development Conference from March 20 to 23, 2019. Potential topics requiring guidance were solicited from ISCD members in 2017. Following that, a steering committee selected, prioritized, and grouped topics into Task Forces. Chairs for each Task Force were appointed and the members were co-opted from suggestions by the Steering Committee and Task Force Chairs. The Task Forces developed key questions, performed literature searches, and came up with proposed initial positions with substantiating draft publications, with support from the Steering Committee. An invited Panel of Experts first performed a review of draft positions using a modified RAND Appropriateness Method with voting for appropriateness. Draft positions deemed appropriate were further edited and presented at the Position Development Conference meeting in an open forum. A second round of voting occurred after discussions to approve or reject the positions. Finally, a face-to-face closed session with experts and Task Force Chairs, and subsequent electronic follow-up resulted in 34 Official Positions of the ISCD approved by the ISCD Board on May 28, 2019. The Official Positions and the supporting evidence were submitted for publication on July 1, 2019. This paper provides a summary of the all the ISCD Adult and Pediatric Official Positions, with the new 2019 positions highlighted in bold.

The worst-case scenario: treatment of periprosthetic femoral fracture with coexistent periprosthetic infection-a prospective and consecutive clinical study.

BACKGROUND: The simultaneous occurrence of periprosthetic fracture (PPF) and periprosthetic joint infection (PJI) is among the most devastating complications in arthroplasty and carries the risk of limb loss. For the first time, this study will describe the characteristics, treatment concepts, and outcomes of this complication. METHODS: Patients were consecutively included who were treated at our specialized interdisciplinary department between 2015 and 2016 with a PJI and an additional PPF of the hip. The treatment algorithm followed a three-step procedure: the complete removal of any foreign material (step 1), fracture stabilization by plate, intramedullary rod osteosynthesis or cerclages using an additional spacer (step 2), and reimplantation of a new prosthesis (step 3). RESULTS: Overall, eight cases [four male, four female, mean age 77 years (55-91)] were included. The mean follow-up was 34 ± 8 months. The fractures included one PPF Vancouver B1, three B2/3, and four type C. Most frequent microbes were CNS (Coagulase-negative staphylococci) (n = 4), Cutibacterium (n = 2) and Staphylococcus aureus (n = 2). Mixed infections (≥ 2 microorganisms) occurred in five cases. The time between explanation and reimplantation was 42 ± 34 (range 7-123) days. A re-infection took place in one, a re-revision in four cases, and in five cases fracture healing was noticed. In all eight cases, freedom from the infection and limb preservation could be achieved. CONCLUSION: PPF in the case of a PJI is a devastating situation and a huge challenge. Extremity preservation should be the primary goal. The described procedure offers a possible solution.

Patellar complications following total knee arthroplasty: a review of the current literature.

Total knee arthroplasty is a common operation for treating patients with end-stage knee osteoarthritis and generally has a good outcome. There are several complications that may necessitate revision of the implants. Patella-related complications are difficult to treat, and their consequences impact the longevity of the implanted joint and functional outcomes. In this review, we explore the current literature on patellar complications in total knee arthroplasty and identify risk factors as well as strategies that can help in preventing these complications. We present pertinent findings relating to patellar complications. They can be classified into bony or soft tissue complications and include bone loss, aseptic loosening, periprosthetic fractures, patella fracture, patellar clunk syndrome, patellofemoral instability, extensor mechanism complications, maltracking, patella baja and malrotation. We conclude that patellar complications in total knee arthroplasty are common and have significant implications for the functional outcome of total knee arthroplasty. A high index of suspicion should be maintained in order to avoid them. Implant malpositioning and other forms of intraoperative technical error are the main cause of these complications, and therefore, primary prevention is crucial. When dealing with these established problems, a clear plan of action should be formulated in advance to allow appropriate management as well as anticipation of adverse outcomes.

[Treatment of Periprosthetic Distal Femoral Fractures]. / Lécení periprotetických zlomenin distálního femuru.

PURPOSE OF THE STUDY Periprosthetic distal femoral fractures (PDFF) constitute an unpleasant complication in patients with a total knee replacement (TKR). The incidence reported in literature is 0.3-2.5 %. The number of periprosthetic knee fractures has been increasing due to the ageing of population, a growing number of implants, a longer life expectancy of patients, a more intensive physical activity of patients, and osteoporosis. Most of these fractures are treated surgically, non-surgical treatment is reserved solely for patients unable to undergo a surgery for general health conditions. MATERIAL AND METHODS Our retrospective study evaluated the group of patients with PDFF who were treated at out department in the period 2007- 2016 and 2,975 primary TKR were performed. The total number of patients with PDFF was 56. The mean age of patients with PDFF was 77 years (56-94 years) and at the time of fracture the mean age was 71 years in men and 78 years in women. The average time from the TKR to periprosthetic fracture was 8.2 years (0-20 years). The fractures were assessed using the Su classification modified by Krbec. RESULTS A primary TKR was performed in 46 cases for gonarthrosis, in 6 cases for rheumatoid arthritis and in 4 cases for secondary, post-traumatic gonarthrosis. The average incidence of periprosthetic distal femoral fractures was 5-6 cases per year. Women represented 86 %, men 14 %. Su Type I fracture was diagnosed in 25 % of cases, Su Type II fractures in 71 %, and Su Type III fractures 4 %. 52 patients with PDFF were treated surgically, in 4 cases conservative treatment was opted for. The average treatment time of PDFF to healing by callus formation was 6.6 months (3-12 months). Mortality during the first 3 months after osteosynthesis of PDFF was 9 %. A failure of osteosynthesis of PDFF was reported in 4 cases. DISCUSSION Multiple classification systems were developed to assess these fractures. The most appropriate we consider the classification of Su et al. classifying the PDFF into 3 groups, namely based on the height of the fracture line relative to the femoral component. Osteosynthesis by retrograde femoral nail is indicated for periprosthetic fractures, with sufficient bone mass in distal femur, which allows stable distal fixation. The new generation of anatomically shaped angular stable implants gives us yet another option for osteosynthesis of PDFF. Many studies point at the advantages of these implants in osteoporotic bone as against the conventional plates. CONCLUSIONS The number of PDFF has been increasing. The main methods of internal osteosynthesis continue to be the angular stable plates and the retrograde femoral nail. Preoperative planning is important to determine the type and dimensions of the existing femoral component and to distinguish whether or not it has come loose. The choice of the implant may depend on the bone mass available for distal fixation. The retrograde femoral nail is usually the most suitable method of treatment for proximal PDFF (Su Type I). The angular stable plates can be used for PDFF originating at the femoral component (Su Type II and Type III). Very distal fractures classified as Su Type III with a loose femoral component require a revision surgery with a TKR with stems. The surgeon should be prepared for a revision surgery if the intraoperative finding is more complicated than anticipated based on the preoperative radiograph. Key words:total knee arthroplasty, periprosthetic fracture, osteosynthesis.