Outcomes in Arthroplasty Procedures Performed for Femoral Neck Fractures Does Approach Affect Outcome?

BACKGROUND: The surgical approach used for arthroplasty in the setting of hip fracture has traditionally been decided based on surgeon preference. This study analyzed the ef-fect of the surgical approach on hospital quality measures, complications, and mortality in patients treated with hip arthroplasty for fracture fixation. METHODS: A cohort of consecutive acute hip fracture pa-tients who were 60 years of age or older and who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) at one academic medical center between January 2014 and January 2018 was included. Patient demographics, length of stay (LOS), surgery details, complications, ambulation at dis-charge, discharge location, readmission, and mortality were recorded. Two cohorts were included based on the surgical approach: the anterior-based cohort included the direct an-terior and anterolateral approaches and the posterior-based cohort included direct lateral and posterior approaches. RESULTS: Two hundred five patients were included: 146 underwent HA (81 anterior-based and 65 posterior-based) and 79 underwent THA (37 anterior-based and 42 posterior-based). The mean age of the HA and THA cohorts was 84.1 ± 7.5 and 73.7 ± 8.0 years, respectively. There was no dif-ference in LOS, time to surgery, or surgical time between the two cohorts for HA and THA. There were no differences in perioperative complications, including dislocation, ob-served based on surgical approach. No difference was found between readmission rates and mortality. CONCLUSION: In this cohort of hip fracture arthroplasty patients, there was no difference observed in hospital quality measures, readmission, or mortality in patients based on sur-gical approach. These results are in contrast with literature in elective arthroplasty patients supporting the use of an anterior approach for potential improved short-term outcomes.

Comparison of the clinical outcomes between proximal femoral nail anti-rotation with cement enhancement and hemiarthroplasty among elderly osteoporotic patients with intertrochanteric fracture.

BACKGROUND: The proximal femoral nail anti-rotation (PFNA) with cement enhancement enhances the anchorage ability of internal fixation in elderly with osteoporotic intertrochanteric fracture. However, whether it is superior to hemiarthroplasty is still controversial. The present study aimed to determine which treatment has better clinical outcomes among older patients. METHODS: We retrospectively analyzed 102 elderly patients with osteoporosis who developed intertrochanteric fractures and underwent PFNA combined with cement-enhanced internal fixation (n = 52, CE group), and hemiarthroplasty (n = 50, HA group) from September 2012 to October 2018. All the intertrochanteric fractures were classified according to the AO/OTA classification. Additionally, the operative time, intraoperative blood loss, intraoperative and postoperative blood transfusion rates, postoperative weight-bearing time, hospitalization time, Barthel Index of Activities Daily Living, Harris score of hip function, visual analog (VAS) pain score, and postoperative complications were compared between the two groups. RESULTS: The CE group had significantly shorter operative time, lesser intraoperative blood loss, lower blood transfusion rate, and longer postoperative weight-bearing time than the HA group. The CE group had lower Barthel's Index of Activities of Daily Living, lower Harris' score, and higher VAS scores in the first and third months after surgery than the HA group, but no difference was observed between the two groups from 6 months to 12 months. There was no significant difference in the total post-operative complications between the two groups. CONCLUSION: The use of PFNA combined with a cement-enhanced internal fixation technique led to shorter operative time and lesser intraoperative blood loss and trauma in elderly patients as compared to HA.

Revision rate in metal compared to ceramic humeral head total shoulder arthroplasty and hemiarthroplasty.

Aims: Metal and ceramic humeral head bearing surfaces are available choices in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) is limited. This study aimed to compare the rates of revision and reoperation following metal and ceramic humeral head TSA and HA using data from the National Joint Registry (NJR), which collects data from England, Wales, Northern Ireland, Isle of Man and the States of Guernsey. Methods: NJR shoulder arthroplasty records were linked to Hospital Episode Statistics and the National Mortality Register. TSA and HA performed for osteoarthritis (OA) in patients with an intact rotator cuff were included. Metal and ceramic humeral head prostheses were matched within separate TSA and HA groups using propensity scores based on 12 and 11 characteristics, respectively. The primary outcome was time to first revision and the secondary outcome was non-revision reoperation. Results: A total of 4,799 TSAs (3,578 metal, 1,221 ceramic) and 1,363 HAs (1,020 metal, 343 ceramic) were included. The rate of revision was higher for metal compared with ceramic TSA, hazard ratio (HR) 3.31 (95% confidence interval (CI) 1.67 to 6.58). At eight years, prosthesis survival for ceramic TSA was 98.7% (95% CI 97.3 to 99.4) compared with 96.4% (95% CI 95.2 to 97.3) for metal TSA. The majority of revision TSAs were for cuff insufficiency or instability/dislocation. There was no significant difference in the revision rate for ceramic compared with metal head HA (HR 1.33 (95% CI 0.76 to 2.34)). For ceramic HA, eight-year prosthetic survival was 92.8% (95% CI 86.9 to 96.1), compared with 91.6% (95% CI 89.3 to 93.5) for metal HA. The majority of revision HAs were for cuff failure. Conclusion: The rate of all-cause revision was higher following metal compared with ceramic humeral head TSA in patients with OA and an intact rotator cuff. There was no difference in the revision rate for HA according to bearing surface.

Risk of complications and implant survival of surgical treatment of proximal femoral metastasis: a meta-analysis.

PURPOSE: The patients with femoral metastasis in the inter- or subtrochanteric area could be treated with intramedullary nailing or prosthetic reconstruction, however, it is controversial which surgical treatment could offer less complications and implant failure. Our purpose was to define the risk of complications and implant survival in patients treated with intramedullary nailing or prosthetic reconstruction. METHODS: We analyzed studies reporting the risk of complications, reoperations and removal of the implant in patients treated with intramedullary nailing, hemiarthroplasty, arthroplasty or megaprosthesis. RESULTS: We analyzed 27 studies (1346 patients) reporting patients treated with intramedullary nail (51%), hemiarthroplasty (15%), arthroplasty (2%), megaprosthesis with (25%) or without (7%) acetabular component. No difference was found in the overall risk of complications between patients treated with intramedullary nailing 6%, hemiarthroplasty or total hip arthroplasty 7% and megaprosthesis 11% (p = 0.23). However, patients treated with megaprosthesis had increased risk of reoperation due to infection (70%), compared to the patients treated with intramedullary nail (13%), and patients treated with hemiarthroplasty or total hip arthroplasty (23%) (p = 0.02). Revision due to disease progression was required in 61% of the patients treated with intramedullary nail, but not in patients treated with hemiarthroplasty, total arthroplasty, and megaprosthesis (p = 0.03). CONCLUSION: Patients treated with megaprosthesis had higher risk of reoperation due to infection, while patients treated with intramedullary nailing had higher risk of revision due to disease progression. Regarding patients treated with megaprosthesis, the risk of reoperation due to dislocation was higher in those treated with acetabular component.

Converting to reverse shoulder arthroplasty from primary anatomic shoulder arthroplasty and fracture hemiarthroplasty: a radiographic and clinical outcome analysis at 8-years.

INTRODUCTION: Revision shoulder arthroplasty can be challenging. One of the main considerations for surgeons is the type of implant that was placed in the initial surgery. Anatomic shoulder arthroplasty (ASA) is used for cases of osteoarthritis as well as for fractures of the humeral head. Hemiarthroplasty can be used for complex proximal humerus fractures. The purpose of this study is to determine whether there is a difference in clinical and radiographic outcomes between patients that failed primary fracture hemiarthroplasty (FHA), or ASA for osteoarthritis and then required reoperation with a conversion to reverse shoulder arthroplasty (RSA). METHODS: Patients with failed anatomic shoulder replacement, who had undergone conversion to RSA, were enrolled after a mean follow-up of 107 (85-157) months. Two different groups, one with failed ASA implanted for osteoarthritis and one with failed FHA, were created. At follow-up patients were assessed with standard radiographs and clinical outcome scores. RESULTS: Twenty-nine patients (f = 17, m = 12; 51%) suffered from a failed ASA (Group A), while the remaining 28 patients (f = 21, m = 74; 49%) had been revised due to a failed FHA (Group B). Patients of Group B had a poorer Constant score (Group A: 60 vs. Group B: 46; p = 0.02). Abduction (Group A: 115° vs. Group B: 89°; p = 0.02) was worse after conversion of a failed FHA to RSA in comparison to conversions of failed ASA. The mean bone loss of the lateral metaphysis was higher in patients with failed FHA (Group A: 5 mm vs. Group B: 20 mm; p = 0.0). CONCLUSION: The initial indication for anatomic shoulder arthroplasty influences the clinical and radiological outcome after conversion to RSA. Conversion of failed FHA to RSA is related to an increased metaphyseal bone loss, decreased range of motion and poorer clinical outcomes when compared to conversions of failed ASA implanted for osteoarthritis. LEVEL OF EVIDENCE: III Retrospective Cohort Comparison Study.

Clinical Outcomes of Bipolar Hemiarthroplasty with a Conjoined Tendon-Preserving Posterior Approach for Femoral Neck Fractures.

Background and Objectives: The conventional posterior approach in the lateral decubitus position is widely used for femoral neck fractures in femoral hemiarthroplasty. Postoperative dislocation is the major problem with this approach. The conjoined tendon-preserving posterior (CPP) approach is a less invasive surgical approach than the conventional posterior approach to the hip, maintains posterior stability, and preserves short external rotators and joint capsules. However, the mention was required to avoid muscle damage and whether muscle damage affects postoperative dislocation or not. The current study aimed to evaluate the clinical results of the CPP approach in hemiarthroplasty for femoral neck fractures and identify muscle damage risk factors. Materials and Methods: This study was a retrospective cohort study and included 170 hips in 168 patients. The mean age at the operation was 81.2 years. The preservation rate of the internal obturator muscle and gemellus inferior muscle and factors related to intraoperative short rotator muscle injury were investigated retrospectively. The postoperative complications and the relation between muscle damage and postoperative dislocation were investigated. Results: In the four hips (2.3%) with the obturator internus muscle damage, thirty-eight hips (22.4%) with gemellus inferior muscle damage were detected; in the muscle-damaged cases, the high body mass index (BMI) was significantly higher. The complication occurred in four hips (2.3%), including postoperative posterior dislocation in one hip without muscle damage (0.6%). Postoperative infection occurred in one hip (0.6%), and peroneal or sciatic nerve paralysis was suspected in two hips (1.1%). Conclusions: Compared to the conventional posterior approach in previous reports, the CPP approach reduces postoperative dislocation. A higher BMI is a risk factor for muscle damage, and the gemellus inferior muscle damage has no effect on postoperative dislocation. The CPP approach for BHA appeared to be an effective treatment method.

Ligament Sparing Elbow Hemiarthroplasty: A Novel Technique for the Management of Distal Humeral Fractures.

Intra-articular distal humerus fractures present various challenges with a wide array of treatment options. Open reduction internal fixation remains the treatment of choice. In older patient populations with poor bone quality and short-end segment fractures with articular comminution, open reduction internal fixation, however, may bring on unsurmountable technical challenges. Total elbow arthroplasty and elbow hemiarthroplasty (EHA) may offer superior functional outcomes in these cases. During EHA for fractures, the medial and lateral columns are reconstructed with the collateral ligaments to restore elbow stability. We hypothesize that in coronal sheer fracture patterns where the columns are intact, maintaining the native collateral ligaments and columns will provide both an anatomic and stable elbow joint. We introduce the ligament sparing EHA technique for unreconstructible coronal shear fractures. We describe this novel technique and compare our postoperative outcomes in 2 patients who underwent this surgery to those described in the literature. The postoperative Disabilities of the Arm, Shoulder, and Hand scores for the 2 patients were 13.8 and 10.3, respectively. The Mayo Elbow Performance Score for the 2 patients were 80 and 85, respectively. The operative arm presented a grip strength of 82% and 89% when compared with the contralateral arm, for the patients respectively. The range of motion varied between 78% and 100% of the contralateral arm for both patients. Although our results are promising and the ligament sparing EHA technique may be a more anatomic option in certain fracture patterns, further research with larger cohorts and multiple surgeons is needed to reinforce our results.

Incidence of dislocation and associated risk factors in patients with a femoral neck fracture operated with an uncemented hemiarthroplasty.

BACKGROUND: Several factors might be associated with risk of dislocating following uncemented hemiarthroplasty (HA) due to femoral neck fracture (FNF). Current evidence is limited with great variance in reported incidence of dislocation (1-15%). Aim of this study was to identify the cumulative incidence of first-time dislocation following HA and to identify the associated risk factors. METHOD: We performed a retrospective cohort study of patients receiving an HA (BFX Biomet stem, posterior approach) at Copenhagen University Hospital, Bispebjerg, in 2010-2016. Patients were followed until death or end of study (dec 2018). Dislocation was identified by code extraction from the Danish National Patient Registry. Variables included in the multivariate model were defined pre-analysis to include: age, sex and variables with a p-value < 0.1 in univariate analysis. A regression model was fitted for 90 days dislocation as the assumption of proportional hazard rate (HR) was not met here after. RESULTS: We identified 772 stems (some patients occurred with both right and left hip) and 58 stems suffered 90 dislocations during the observation period, resulting in a 7% (CI 5-9) incidence of dislocation 90 days after index surgery. 55 of the 58 stems (95%) experienced the first dislocation within 90 days after surgery. Only absence of dementia was identified as an independent protective factor in the cause-specific model (HR 0.46 (CI 0.23-0.89)) resulting in a 2.4-fold cumulative risk of experiencing a dislocation in case of dementia. Several other variables such as age, sex, various medical conditions, surgery delay and surgical experience were eliminated as statistical risk factors. We found a decrease in survival probability for patients who experienced a dislocation during follow-up. CONCLUSIONS: The incidence of first-time dislocation of HA (BFX Biomet stem, posterior approach) in patients with a hip fracture is found to be 7% 90 days after surgery. Due to the non-existing attribution bias, we claim it to be the true incidence. Dementia was among several variables identified as the only risk factor for dislocation. In perspective, we may consider treating patients with dementia by other methods than HA e.g., HA with cement or with a more constrained solution. Also, a surgical approach that reduce the risk of dislocation should be considered.

Replacing hip precautions after hemiarthroplasty with a pose avoidance protocol.

AIMS: After hip arthroplasty surgery, hip precautions are often implemented to minimise the risk of dislocation, although existing evidence does not support their effectiveness. At our institution, we replaced post-operative precautions with a novel pose avoidance protocol in patients undergoing hip hemiarthroplasty for neck of femur fracture. The objectives of our study were to validate this new protocol by assessing the incidence of dislocation before and after its introduction and evaluating its impact on the length of hospital stay. METHODS: Between 20th September 2021 and 19th March 2023, 200 patients underwent 203 hip hemiarthroplasties. Hip precautions were replaced with the new pose avoidance protocol on 20th June 2022. Data were retrospectively collected and included patient demographics, Abbreviated Mental Test Score, American Society of Anaesthesiologists grade, surgical approach, prosthesis, dislocation, and mortality. RESULTS: The incidence of dislocation within 90 days after hip hemiarthroplasty decreased from seven out of 98 cases (7.1%) before 20th June 2022 to one out of 105 cases (1.0%), p-value 0.030. However, there was no significant difference in the length of stay, with a median (interquartile range) of 19 (10 - 29) days before 20th June 2022, and 16 (11 - 22) days thereafter, p-value 0.242. A multivariate logistic regression confirmed the pose avoidance protocol and the anterolateral approach to be independent negative predictors of dislocation, p-value 0.030 (Odds Ratio [OR] 0.077) and p-value 0.005 (OR 0.022), respectively. CONCLUSIONS: Hip precautions are unnecessary and potentially detrimental to patient outcomes following hemiarthroplasty. Replacing these precautions with our new pose avoidance protocol may have led to a significant reduction in dislocation rates and saved on the cost of adaptive equipment. We advocate for the anterolateral over the posterior approach in hip hemiarthroplasty to further mitigate the risk of dislocation. LEVEL OF EVIDENCE: IV.

Patient-related Predictors for the Functional Outcome of SuperPATH Hemiarthroplasty versus Conventional Approach Hemiarthroplasty: A Systematic Review and Meta-regression Analysis of Randomized Controlled Trials.

Specialist literature lacks evidence that explores associations between patient characteristics and the beneficial treatment effect of SuperPATH hemiarthroplasty (HA) compared with conventional approach (CA) HA. To investigate and identify patient-related predictors of the effect size of the short-term functional outcome of SuperPATH HA and CA HA by performing a systematic review and meta-regression analysis of randomized controlled trials (RCTs). A systematic search of literature was performed in PubMed, CNKI, CENTRAL of The Cochrane Library, Clinical trials, and Google Scholar until August 25, 2023. For the continuous outcome parameter Harris hip score (HHS) ≤1 week and 3 months postoperatively, mean differences (MDs) with 95% confidence intervals (CIs) were calculated. A meta-regression analysis was based on random-effects meta-analysis using the Hartung-Knapp-Sidik-Jonkman method for continuous covariates. A total of five RCTs with 404 patients were found. The following predictors of HHS ≤1 week postoperatively were identified: patient age (predictor estimate = 1.29; p < 0.01), patient age groups (predictor estimate = 14.07; p < 0.01), time to mobilization (predictor estimate = 5.51; p < 0.01). The following predictors of HHS 3 months postoperatively were identified: incision length (predictor estimate = -2.12; p < 0.01); intraoperative blood loss (predictor estimate = 0.02; p < 0.01). Patient age, time to mobilization, incision length, and intraoperative blood loss were identified as predictors of the effect size of early postoperative functional outcome as measured by HHS. Elderly patients, particularly those over 70 years of age, appear to benefit from SuperPATH HA. Based on these findings, and taking into account our limitations, we recommend that the use of minimally invasive SuperPATH HA in elderly patients should be more widely considered and not limited to elective THA patients.

Unipolar Hemiarthroplasty, Bipolar Hemiarthroplasty, or Total Hip Arthroplasty for Hip Fracture in Older Individuals.

BACKGROUND: Practice patterns regarding the use of unipolar hemiarthroplasty, bipolar hemiarthroplasty, and total hip arthroplasty (THA) for femoral neck fractures in older patients vary widely. This is due in part to limited data stipulating the specific circumstances under which each form of arthroplasty provides the most predictable outcome. The purpose of this study was to investigate the patient characteristics for which unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA might be preferable due to a lower risk of all-cause revision. METHODS: A U.S. health-care system's hip fracture registry was used to identify patients ≥60 years old who underwent unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA for hip fracture from 2009 through 2021. Unipolar and bipolar hemiarthroplasty were compared with THA within patient subgroups defined by age (60 to 79 versus ≥80 years) and American Society of Anesthesiologists (ASA) classification (I or II versus III); patients with an ASA classification of IV or higher were excluded. Multivariable Cox proportional hazard regression analysis was used to evaluate all-cause revision risk while adjusting for confounders, with mortality considered as a competing risk. RESULTS: There were 14,277 patients in the final sample (median age, 82 years; 70% female; 80% White; 69% with an ASA classification of III; median follow-up, 2.7 years), and the procedures included 7,587 unipolar hemiarthroplasties, 5,479 bipolar hemiarthroplasties, and 1,211 THAs. In the multivariable analysis of all patients, both unipolar (hazard ratio [HR] = 2.15, 95% confidence interval [CI] = 1.48 to 3.12; p < 0.001) and bipolar (HR = 1.92, 95% CI = 1.31 to 2.80; p < 0.001) hemiarthroplasty had higher revision risks than THA. In the age-stratified multivariable analysis of patients aged 60 to 79 years, both unipolar (HR = 2.17, 95% CI = 1.42 to 3.34; p = 0.004) and bipolar (HR = 1.69, 95% CI = 1.08 to 2.65; p = 0.022) hemiarthroplasty also had higher revision risks than THA. In the ASA-stratified multivariable analysis, patients with an ASA classification of I or II had a higher revision risk after either unipolar (HR = 3.52, 95% CI = 1.87 to 6.64; p < 0.001) or bipolar (HR = 2.31, 95% CI = 1.19 to 4.49; p = 0.013) hemiarthroplasty than after THA. No difference in revision risk between either of the hemiarthroplasties and THA was observed among patients with an age of ≥80 years or those with an ASA classification of III. CONCLUSIONS: In this study of hip fractures in older patients, THA was associated with a lower risk of all-cause revision compared with unipolar and bipolar hemiarthroplasty among patients who were 60 to 79 years old and those who had an ASA classification of I or II. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Effect of anaesthesia on cemented hemiarthroplasty -A multicentre retrospective study (TRON study).

INTRODUCTION: This study aimed to investigate the survival rate, postoperative complications, and walking ability in cemented hemiarthroplasty (HA) for displaced femoral neck fractures according to the anaesthesia method. METHODS: We conducted a retrospective study of a multicentre group (the TRON group). Three hundred fifty-eight patients who underwent cemented HA between 2015 and 2019 were selected; 289 patients of ≥75 years of age with no missing data were included. Patient background factors were matched and patients were assigned to spinal anaesthesia (SA) and general anaesthesia (GA) groups. The primary outcome was death at any time during the follow-up period. Secondary outcomes included postoperative complications and walking ability assessed using the Parker mobility score (PMS). Overall survival was evaluated using the Kaplan-Meier method, and differences were compared using the log-rank test. The incidence of each complication and PMS were compared between the two groups using Fisher's exact test. RESULTS: Overall survival during follow-up was significantly higher in the SA group in comparison to the GA group (p = 0.037). In the SA and GA groups, the survival rate at 3 months postoperatively was 98.4% and 95.5%, respectively. The incidence of postoperative pneumonia was significantly higher in the GA (p = 0.012), and PMS at 3 months postoperatively was significantly higher in the SA group (p = 0.016). CONCLUSION: The survival rate of elderly patients who underwent cemented HA was better in the SA group. General anaesthesia in cemented HA may be associated with lower life expectancy, increased incidence of pneumonia, and decreased walking ability.

Clinical and radiographic long-term outcomes of hemiarthroplasty for complex proximal humeral fractures.

BACKGROUND: Hemiarthroplasty (HA) is a treatment option for complex proximal humeral fractures not suitable for conservative treatment or open reduction-internal fixation. Long-term outcomes using a large-metaphyseal volume prosthesis in the management of proximal humeral fractures have not been reported thus far. METHODS: Between 2006 and 2010, 41 patients with proximal humeral fractures were treated with HA at our institution (average age, 62 years; age range, 38-85 years). Nine patients underwent revision surgery, 3 were lost to follow-up, and 7 died unrelated to the index surgical procedure. Twenty-two patients were reviewed clinically and radiographically after a mean period of 10.4 years (range, 9-13 years). RESULTS: Of the 9 HA failures, 7 occurred within the first 2 postoperative years: 2 patients had infections and 5 had greater tuberosity nonunions or malunions. The other 2 patients underwent revision for rotator cuff deficiency >5 years after initial surgery. Among the patients available for final follow-up, the implant survival rate was 71% (22 of 31 patients). At final follow-up, these patients showed a mean relative Constant score of 76% (range, 49%-96%), mean active elevation of 116° (range, 60°-170°), and mean external rotation of 28° (range, 0°-55°). The majority had good or excellent internal rotation, with internal rotation to the 12th thoracic vertebra in 13 patients (59%) and to the eighth thoracic vertebra in 7 (31%). The mean Subjective Shoulder Value was 76% (range, 40%-100%). Clinical outcomes did not significantly deteriorate over a period of 10 years, except for flexion (P < .001) and internal rotation (P = .002). On analysis of greater tuberosity healing, 1 patient had a nonunion and 10 patients (45%) had a malunion, whereas the greater tuberosity had healed in an anatomic position in 12 patients (55%). Patients with a displaced malunion of the greater tuberosity did not have inferior clinical results at last follow-up. Only 2 patients showed glenoid erosion, and in no patients could stem loosening be identified at final follow-up. CONCLUSION: The revision rate following large-metaphyseal volume HA to treat a proximal humeral fracture was 29% after 10 years postoperatively, with failure within 2 years largely related to greater tuberosity nonunion or malunion and failure later related to rotator cuff insufficiency. Patients with a retained implant showed good clinical and radiographic long-term results, without relevant deterioration over time even when the greater tuberosity healed in a nonanatomic position.

The long-term results of shoulder hemiarthroplasty in irreducible four-part fracture-dislocation of the proximal humerus without rotator cuff tear arthropathy.

PURPOSE: Although there are concerns about nonunion of the greater tuberosity or shoulder weakness, hemishoulder arthroplasty (HSA) is a viable treatment option for irreducible four-part proximal humerus fractures-dislocation without rotator cuff tear arthropathy. This study aims to analyze the long-term radiological and functional outcomes of HSA. METHODS: This study enrolled 36 patients who underwent HSA due to irreducible four-part proximal humerus fracture-dislocation without rotator cuff tear arthropathy between March 2005 and May 2020. The exclusion group included 10 reverse total shoulder arthroplasty patients. The mean age and mean follow-up period were 68.6 years old and 48.6 months, respectively. Radiological assessments, such as vertical and horizontal greater tuberosity position, greater tuberosity healing, and implant position, were evaluated. Clinically, American Shoulder and Elbow Surgeons Score (ASES), Constant-Murley Score (CMS), and range of motion were evaluated. RESULTS: The greater tuberosity union rate was 55.6% (n = 20), with 44.4% (n = 16) experiencing nonunion, malunion, and bone resorption. The mean vertical and horizontal greater tuberosity positions showed significant difference at last follow-up compared to immediate postoperation. The retroversion of the implant was 23.8 ± 4.61°, and the acromio-humeral interval was 7.6 ± 1.34 mm. The mean last follow-up ASES and CMS were 39.5 ± 4.03 and 55.4 ± 10.41, respectively. The mean active forward flexion, abduction, internal rotation, and external rotation were 100.9 ± 15.04°, 92.5 ± 14.47°, 44.2 ± 12.83°, and 42.5 ± 15.32°, respectively. CONCLUSION: In long-term follow-up, the greater tuberosity was superiorly migrated and externally rotated. Active forward flexion and abduction in the last follow-up were significantly limited. However, in terms of pain relief, a satisfactory result was seen.

Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial.

BACKGROUND: Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients. MATERIAL AND METHODS: This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60 years and independent living. The final follow-up took place after ≥2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength. RESULTS: Forty patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = .30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = .39), a difference of -5.6 points (95% CI: -18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = .59), EQ-5D index (0.92 vs. 0.86, P = .13), extension (29° vs. 29°, P = .98), flexion (126° vs. 136°, P = .05), arc of flexion-extension (97° vs. 107°, P = .25), supination (81° vs. 75°, P = .13), pronation (78° vs. 74°, P = .16) or grip strength (17.5 kg vs. 17.2 kg, P = .89). There were 6 adverse events in each treatment group. CONCLUSION: In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.

Predicting Prolonged Wound Drainage after Hemiarthroplasty for Hip Fractures: A Stacked Machine Learning Study.

Background: Prolonged wound drainage (PWD) is one of the most important reasons that increase the risk of early periprosthetic joint infection after arthroplasty. It is very important to evaluate the risk factors for PWD in the surgical field after arthroplasty surgery. This can be accomplished using machine learning or artificial intelligence methods. Our aim in this study was to compare machine learning methods in predicting possible PWD. Methods: The study was carried out on clinical, laboratory, and radiological data of 313 patients who underwent hemiarthroplasty (HA) for proximal femur fractures. We preprocessed the dataset and trained and tested machine learning methods using cross validation. We compared various machine learning algorithms (linear discriminant analysis, decision tree, k-nearest neighbors, gradient boosting machine, and logistic regression [LR]) based on performance measures. We also combined the most successful algorithms with a metaclassifier. To help understand the relationship between risk factors, we provided a risk factor severity ranking. Results: To estimate the risk of PWD, classification was performed with first-level classifiers and then integrated as a LR-based meta-learner stacking method. More performance improvements were achieved with the stacking method. Conclusions: We found that the stacking method was superior to other methods in PWD classification. We determined that the volume of fluid collected from the drain, morbid obesity class, blood transfusion, and body mass index score were the four most important risk factors according to stacking.

Better Short-term Outcomes after Total Hip Arthroplasty Compared to Hemiarthroplasty in Active Older Patients with Displaced Intracapsular Femoral Neck Fracture.

BACKGROUND: Hip fractures are a public health problem that disproportionately affects the elderly. Displaced femoral neck fractures were treated historically with hemiarthroplasty, but the use of total hip arthroplasty (THA) is increasing showing superior long-term results. OBJECTIVES: To assess whether THA has superior short-term results compared to bipolar hemiarthroplasty for displaced femoral neck fractures. METHODS: Two groups of active older patients underwent either cementless bipolar hemiarthroplasty or THA for displaced femoral neck fracture. All patients were operated on using the direct lateral approach to the hip joint. Patients were assessed using the Harris Hip Score at hospital discharge and at 6 weeks follow-up. RESULTS: We included 40 patients ages 65-85 years; 18 underwent bipolar hemiarthroplasty and 22 THA. The number of women in each group was similar, as was mean age: 73.1 ± 4.2 years in the hemiarthroplasty group and 71.0 ± 3.7 in THA. Harris Hip Score on hospital discharge was similar in both groups. Walking ability at discharge was better in the THA cohort and they were discharged sooner: 5.2 ± 1.3 vs. 6.4 ± 1.7 days following hemiarthroplasty (P = 0.021). At 6 weeks follow-up, the mean Harris Hip Score was higher in the THA group (78.6 ± 11 vs. 61.5 ± 17 for hemiarthroplasty, P < 0.001). Patients in the THA group walked longer distances, needed less support while walking, and reported less pain. CONCLUSIONS: Better short-term results at hospital discharge and at 6 weeks follow-up after THA contributed to earlier patient independence and shorter hospital stays.