Clinical Applications of "In-Hospital" 3D Printing in Hip Surgery: A Systematic Narrative Review.

Introduction: Interest in 3D printing for orthopedic surgery has been increasing since its progressive adoption in most of the hospitals around the world. The aim of the study is to describe all the current applications of 3D printing in patients undergoing hip surgery of any type at the present time. Materials and Methods: We conducted a systematic narrative review of publications indexed in MedLine through the search engine PubMed, with the following parameters: 3D printing AND (orthopedics OR traumatology) NOT tissue engineering NOT scaffold NOT in vitro and deadline 31 July 2023. After reading the abstracts of the articles, papers were selected according to the following criteria: full text in English or Spanish and content related to hip surgery. Those publications involving experimental studies (in vitro or with anatomical specimens) or 3D printing outside of hospital facilities as well as 3D-printed commercial implants were excluded. Results are presented as a reference guide classified by disease, including the used software and the steps required for the development of the idea. Results: We found a total of 27 indications for in-house 3D printing for hip surgery, which are described in the article. Conclusions: There are many surgical applications of 3D printing in hip surgery, most of them based on CT images. Most of the publications lack evidence, and further randomized studies should be encouraged to assess the advantages of these indications.

Dual Mobility Cups as the Routine Choice in Total Hip Arthroplasty.

Background and Objectives: Total hip arthroplasty (THA) is considered the most successful surgical procedure in orthopedics. However, dislocation remains the main indication for surgical revision. New designs of dual mobility cups (DMC) have lowered the classical complications and have extended the indications of DMC in elective surgeries. Our aim is to assess the trend of DMC indications in THA as well as the incidence of their dislocation. Materials and Methods: We retrospectively reviewed all patients undergoing THA with DMC during the years 2015 and 2021. The original indication for DMC included patients sustaining neck of femur fractures (NOF#) and associated risk factors for dislocations. Five years later, DMC was considered our standard of care in total hip arthroplasty. The approach (anterolateral or posterolateral) was chosen by the surgeon according to his/her preferences, as was the implant. Data collected included patients' demographics, diagnosis, admission time, surgical approach, cup models, and inclination and complications. Patients sustaining a hip dislocation were prospectively reviewed and assessed for treatment received, new dislocations, and need for surgical revision. Two groups were created for the analysis according to the presence or absence of dislocation during follow-up. Results: In the analysis, 531 arthroplasties were included (mean age 72.2 years) with a mean follow-up of 2.86 years. The trend of indications for DMC increased from 16% of THA in 2015 to 78% of THA in 2021. We found a total of 8 dislocations (1.5%), none of them associated with elective surgery. Closed reduction was unsatisfactory in four cases (50%). There was one case of intraprosthetic dislocation. Dislocations were associated to smaller heads (22 mm) (1.5% vs. 25%, p = 0.008) and cups (51.2 mm vs. 48.7 mm, p = 0.038) and posterior approach (62.5% vs. 37.5%, p = 0.011). Conclusion: Dual mobility cups are a great option to reduce the risk of dislocation after a THA both in the neck of femur fractures and elective cases. The use of an anterolateral approach in THA after a neck or femur fracture might considerably decrease the risk of dislocation.

In-hospital care, complications, and 4-month mortality following a hip or proximal femur fracture: the Spanish registry of osteoporotic femur fractures prospective cohort study.

We have characterised 997 hip fracture patients from a representative 45 Spanish hospitals, and followed them up prospectively for up to 4 months. Despite suboptimal surgical delays (average 59.1 hours), in-hospital mortality was lower than in Northern European cohorts. The secondary fracture prevention gap is unacceptably high at 85%. PURPOSE: To characterise inpatient care, complications, and 4-month mortality following a hip or proximal femur fracture in Spain. METHODS: Design: prospective cohort study. Consecutive sample of patients ≥ 50 years old admitted in a representative 45 hospitals for a hip or proximal femur fragility fracture, from June 2014 to June 2016 and followed up for 4 months post-fracture. Patient characteristics, site of fracture, in-patient care (including secondary fracture prevention) and complications, and 4-month mortality are described. RESULTS: A total of 997 subjects (765 women) of mean (standard deviation) age 83.6 (8.4) years were included. Previous history of fracture/s (36.9%) and falls (43%) were common, and 10-year FRAX-estimated major and hip fracture risks were 15.2% (9.0%) and 8.5% (7.6%) respectively. Inter-trochanteric (44.6%) and displaced intra-capsular (28.0%) were the most common fracture sites, and fixation with short intramedullary nail (38.6%) with spinal anaesthesia (75.5%) the most common procedures. Surgery and rehabilitation were initiated within a mean 59.1 (56.7) and 61.9 (55.1) hours respectively, and average length of stay was 11.5 (9.3) days. Antithrombotic and antibiotic prophylaxis were given to 99.8% and 98.2% respectively, whilst only 12.4% received secondary fracture prevention at discharge. Common complications included delirium (36.1 %) and kidney failure (14.1%), with in-hospital and 4-month mortality of 2.1% and 11% respectively. CONCLUSIONS: Despite suboptimal surgical delay, post-hip fracture mortality is low in Spanish hospitals. The secondary fracture prevention gap is unacceptably high at > 85%, in spite of virtually universal anti-thrombotic and antibiotic prophylaxis.

Incidence of bone protection and associated fragility injuries in patients with proximal femur fractures.

OBJECTIVES: Our aim was to investigate whether patients presenting with fragility fractures of the proximal femur are receiving osteoporosis treatment and to assess the number of other fragility fractures they have sustained prior to admission. METHODS: All patients presenting to our institution with fragility fractures of the proximal femur within an 18-month period (January 2012-August 2013) were included. Patient demographics; fracture classification (AO/OTA); American Society of Anesthesiologists (ASA) grade; Abbreviated Mental Test Score (AMTS) on admission; type of operation; time to operation; peri-operative complications; length of hospital stay (LOS); walking status; osteoporotic medication; Dual-energy X-ray absorptiometry (DEXA) results; additional fragility fractures; and mortality were collected and analysed. RESULTS: A total of 1004 patients (278 male) met the inclusion criteria and were included into the study. The mean age was 82.01 years and mean LOS was 19.54days. Fifty-four per cent of the patients were admitted from their own homes whereas 43% were capable to walk indoors without any aids before their injury. Mean time to surgery was 2.06days (Median: 1.31, range: 0-26days). Three hundred and six patients (30.5%) had at least another fragility fracture before the index episode (mean 1.40 fractures; SD: 0.71 fractures; range: 1-6 fractures). Only 16.4% were under complete osteoporosis treatment on admission, defined as receiving calcium with vitamin D and a bisphosphonate or an alternative agent. When we compared patients without a history of a previous fragility fracture (Group A) and patients with at least another previous fragility fracture (Group B), we found that patients in Group B had a significantly lower AMTS score, lower bone mineral density (BMD) as evident on the DEXA scan, an inferior mobility before admission and a higher incidence of extracapsular fractures (p<0.05). On discharge, patients in Group B had a higher chance of receiving complete bone protection compared to group A (27.9% versus 41.7%; p<0.01). Following discharge, 11.2% of the patients sustained an additional fragility fracture. The mean time from the index episode to the additional fracture was 0.65 years, whilst these injuries were more frequent in Group B (RR=1.638; p<0.05). CONCLUSION: Patients presenting with a hip fracture are generally under-treated for osteoporosis. Post-operative assessment by a designated geriatrician and use of a standardised protocol is of paramount importance for reducing the risk of additional fragility fractures. Additionally, screening of the elderly population for identifying the patients who suffer from osteoporosis can potentially reduce the risk of sustaining a further fragility fracture.

Hip osteoarthritis as a predictor of the fracture pattern in proximal femur fractures.

INTRODUCTION: Several authors have suggested a correlation between the fracture patterns of proximal femur fractures and the degree of hip osteoarthritis (HOA), but the current evidence to support this are insufficient. The aim of our study was to demonstrate whether there is an association between the grade of HOA and fracture pattern observed, in patients presenting with a fragility fracture of the proximal femur. MATERIALS AND METHODS: We contacted a retrospective review of all patients presenting to our institution with fragility fractures involving the proximal femur, between March 2012 and October 2013. Pathological fractures, high-energy injuries and patients with less than one year of follow-up were excluded from further analysis. Admission radiographs and severity of HOA were assessed according to Kellgren and Lawrence scale (minimal: Grades 1-2; severe: Grades 3-4). Fractures were classified according to AO/OTA classification. RESULTS: A total of 1003 patients (725 females; 1003 fractures) met the inclusion criteria, having a mean age of 81.5 (46-106 years). With regards to fracture classification, 417 (41.6%) fractures were classified as extracapsular and 586 (58.4%) as intracapsular. A total of 939 (93.9%) patients presented with minimal HOA, whilst 61 (6.1%) of the patients presented with severe HOA. Of the 61 patients presenting with severe HOA, 42 patients (68.9%) sustained a 31A-interthrocanteric fracture and 19 patients (31.1%) sustained a 31B-intracapsular fracture. Regarding the patients presenting with minimal HOA (832 patients in total), 323 patients (38.8%) sustained 31A-intertrochanteric fracture and 509 patients (61.2%) sustained a 31B-intracapsular fracture. Patients presenting with severe HOA were found to have a statistically significant chance to present with an extracapsular fracture (p<0.01). CONCLUSIONS: The degree of HOA is related to the fracture pattern in patients presenting following simple mechanical falls. More specifically, higher grades of HOA are associated with extracapsular fracture patterns, whereas lower grades of HOA are associated with intracapsular fracture patterns.