The Unified Classification System (UCS) was introduced because of a growing need to have a standardised universal classification system of periprosthetic fractures. It combines and simplifies many existing classification systems, and can be applied to any fracture around any partial or total joint replacement occurring during or after operation. Our goal was to assess the inter- and intra-observer reliability of the UCS in association with knee replacement when classifying fractures affecting one or more of the femur, tibia or patella. We used an international panel of ten orthopaedic surgeons with subspecialty fellowship training and expertise in adult hip and knee reconstruction (‘experts’) and ten residents of orthopaedic surgery in the last two years of training (‘pre-experts’). They each received 15 radiographs for evaluation. After six weeks they evaluated the same radiographs again but in a different order. . The reliability was assessed using the Kappa and weighted Kappa values. The Kappa values for inter-observer reliability for the experts and the pre-experts were 0.741 (95% confidence interval (CI) 0.707 to 0.774) and 0.765 (95% CI 0.733 to 0.797), respectively. The weighted Kappa values for intra-observer reliability for the experts and pre-experts were 0.898 (95% CI 0.846 to 0.950) and 0.878 (95% CI 0.815 to 0.942) respectively. The UCS has substantial inter-observer reliability and ‘near perfect’ intra-observer reliability when used for periprosthetic fractures in association with knee replacement in the hands of experienced and inexperienced users. Cite this article: Bone Joint J 2014;96-B:1669–73

Aims. United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures. Methods. A retrospective review was conducted of all patients who underwent revision THA (rTHA) for periprosthetic UCS B2 and B3 periprosthetic fracture who received a single design monoblock fluted tapered titanium stem at two large, tertiary care, academic hospitals. A total of 72 patients met inclusion and exclusion criteria (68 UCS B2, and four UCS B3 fractures). Primary outcomes of interest were radiological stem subsidence (> 5 mm), radiological osseointegration, and fracture union. Sub-analysis was also done for 46 patients with minimum one-year follow-up. Results. For the total cohort, stem osseointegration, fracture union, and stem subsidence were 98.6%, 98.6%, and 6.9%, respectively, at latest follow-up (mean follow-up 27.0 months (SD 22.4)). For patients with minimum one-year of follow-up, stem osseointegration, fracture union, and stem subsidence were 97.8%, 97.8%, and 6.5%, respectively. Conclusion. Monoblock fluted stems can be an acceptable modality for the management of UCS B2 periprosthetic fractures in rTHAs due to high rates of stem osseointegration and survival, and the low rates of stem subsidence, and revision. Further research on the use of this stem for UCS B3 periprosthetic fractures is warranted to determine if the same conclusion can be made for this fracture pattern. Cite this article: Bone Jt Open 2023;4(8):551–558

Aims. The aim of this study was to investigate the outcome of periprosthetic fractures of the humerus and to assess the uniformity of the classifications used for these fractures (including those around elbow and/or shoulder arthroplasties) by performing a systematic review of the literature. Methods. A systematic search was conducted using the National Institute for Health and Care Excellence Healthcare Databases Advance Search. For inclusion, studies had to report clinical outcomes following the management of periprosthetic fractures of the humerus. The protocol was registered on the PROSPERO database. Results. Overall, 40 studies were included, involving a total of 210 patients. The fractures were reported using very heterogeneous classification systems, as were the functional outcome scores. A total of 60 patients had nonoperative treatment with a 50% rate of nonunion. Fixation was undertaken in 99 patients; successful union was obtained in 93 (93%). Revision of either the humeral stem or the whole arthroplasty was reported in 79 patients with a high rate of union (n = 66; 84%), and a mean rate of complications of 29% (0% to 41%). Conclusion. This study highlighted a lack of uniformity in classifying these fractures and reporting the outcome of their treatment. The results may help to inform decision-making with patients, particularly about the rate of complications of nonoperative treatment. There is a need to improve the reporting of the pattern of these fractures using a uniform classification system, and the harmonization of the collection of data relating to the outcome of treatment. Based on this review, we propose a minimum dataset to be used in future studies. Cite this article: Bone Joint J 2022;104-B(4):416–423

Aims. Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures. Methods. We identified all periprosthetic fractures around a hip or knee arthroplasty from our prospectively collated database between 2012 and 2021. Patients were categorized into early or delayed intervention based on time from admission to surgery (early = ≤ 36 hours, delayed > 36 hours). Patient demographics, existing implants, Unified Classification System fracture subtype, acute medical issues on admission, preoperative haemoglobin, blood transfusion requirement, and length of hospital stay were identified for all patients. Complication and mortality rates were compared between groups. Results. A total of 365 patients were identified: 140 in the early and 225 in the delayed intervention group. Mortality rate was 4.1% at 30 days and 19.2% at one year. There was some indication that those who had surgery within 36 hours had a higher mortality rate, but this did not reach statistical significance at 30 days (p = 0.078) or one year (p = 0.051). Univariate analysis demonstrated that age, preoperative haemoglobin, acute medical issue on admission, and the presence of postoperative complications influenced 30-day and one-year mortality. Using a multivariate model, age and preoperative haemoglobin were independently predictive factors for one-year mortality (odds ratio (OR) 1.071; p < 0.001 and OR 0.980; p = 0.020). There was no association between timing of surgery and postoperative complications. Postoperative complications were more likely with increasing age (OR 1.032; p = 0.001) and revision arthroplasty compared to internal fixation (OR 0.481; p = 0.001). Conclusion. While early intervention may be preferable to reduce prolonged immobilization, there is no evidence that delaying surgery beyond 36 hours increases mortality or complications in patients with a femoral periprosthetic fracture. Cite this article: Bone Jt Open 2024;5(6):452–456

Abstract. Objective. To compare the periprosthetic fracture mechanics between a collared and collarless fully coated cementless femoral stem in a composite femur. Methods. Two groups of six composite femurs (‘Osteoporotic femur’, SawBones, WA USA) were implanted with either a collared (collared group) or collarless (collarless group) cementless femoral stem which was otherwise identical by a single experienced surgeon. Periprosthetic fractures of the femur were simulated using a previously published technique. High speed video recording was used to identify fracture mechanism. Fracture torque and angular displacement were measured and rotational work and system stiffness were estimated for each trial. Results were compared between collared and collarless group and the comparison was evaluated against previously published work using fresh frozen femurs and the same protocol. Results. In composite femur testing median fracture torque (IQR) was greater with a collared versus collarless implant (48.41 [42.60 to 50.27] Nm versus 45.12 [39.13 to 48.09] Nm, p= 0.4). Median rotational displacement (IQR) was less with a collared versus collarless implant (0.29 [0.27 to 0.31] radians versus 0.33 [0.32 to 0.34] radians, p= 0.07). Estimated rotary work was similar between groups (5.76 [4.92 to 6.64] J versus 5.21 [4.25 to 6.04] J, p= 0.4). Torsional stiffness was greater with a collared versus collarless implant (158.36 [152.61, 163.54] Nm per radian versus 138.79 [122.53, 140.59] Nm per radian, p= 0.5). Collarless stems were seen to move independently of the femur and fracture patterns originated at the calcar. Conclusions. Testing with composite femurs using an established protocol produced similar results to previously published studies using human femurs, but the difference between collared and collarless stems was smaller. The internal homogenous foam material in composite femurs does not accurately represent the heterogeneous cancellous bone which supports a femoral stem in vivo and may lead to overestimation of implant stability. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Aims. The aim of this study was to describe the demographic details of patients who sustain a femoral periprosthetic fracture (PPF), the epidemiology of PPFs, PPF characteristics, and the predictors of PPF types in the UK population. Methods. This is a multicentre retrospective cohort study including adult patients presenting to hospital with a new PPF between 1 January 2018 and 31 December 2018. Data collected included: patient characteristics, comorbidities, anticoagulant use, social circumstances, level of mobility, fracture characteristics, Unified Classification System (UCS) type, and details of the original implant. Descriptive analysis by fracture location was performed, and predictors of PPF type were assessed using mixed-effects logistic regression models. Results. In total, 720 femoral PPFs from 27 NHS sites were included. PPF patients were typically elderly (mean 79.9 years (SD 10.6)), female (n = 455; 63.2%), had at least one comorbidity (n = 670; 93.1%), and were reliant on walking aids or bed-/chair-bound prior to admission (n = 419; 61.7%). The study population included 539 (74.9%) hip PPFs, 151 (21.0%) knee PPFs, and 30 (4.2%) dividing type PPFs. For hip (n = 407; 75.5%) and knee (n = 88; 58.3%) arthroplasty UCS B type fractures were most common. Overall, 556 (86.2%) were treated in the presenting hospital and 89 (13.8%) required transfer for treatment. Female sex was the only significant predictor of fracture type (A/B1/C type versus B2/B3) for femoral hip PPFs (odds ratio 0.61 (95% confidence interval 0.41 to 0.91); p = 0.014). Sex, residence type, primary versus revision implant PPF, implant fixation, and time between arthroplasty and PPF were not found to predict fracture type for hip PPFs. Conclusion. This multicentre analysis describes patient and injury factors for patients presenting with femoral PPFs to centres across the UK. These patients are generally elderly and frail, comparable to those sustaining a hip fracture. These data can be useful in planning future services and clinical trials. Cite this article: Bone Joint J 2022;104-B(8):987–996

Aims. The aim of this study was to describe the management and associated outcomes of patients sustaining a femoral hip periprosthetic fracture (PPF) in the UK population. Methods. This was a multicentre retrospective cohort study including adult patients who presented to 27 NHS hospitals with 539 new PPFs between 1 January 2018 and 31 December 2018. Data collected included: management strategy (operative and nonoperative), length of stay, discharge destination, and details of post-treatment outcomes (reoperation, readmission, and 30-day and 12-month mortality). Descriptive analysis by fracture type was performed, and predictors of PPF management and outcomes were assessed using mixed-effects logistic regression. Results. In all, 417 fractures (77%) were managed operatively and 122 (23%) conservatively. The median time to surgery was four days (interquartile range (IQR) 2 to 7). Of those undergoing surgery, 246 (59%) underwent revision and/or fixation and 169 (41%) fixation alone. The surgical strategy used differed by Unified Classification System for PPF type, with the highest rate of revision in B2/B3 fractures (both 77%, 176/228 and 24/31, respectively) and the highest rate of fixation alone in B1- (55/78; 71%) and C-type (49/65; 75%) fractures. Cemented stem fixation (odds ratio (OR) 2.66 (95% confidence interval (CI) 1.42 to 4.99); p = 0.002) and B2/B3 fracture type (OR 7.56 (95% CI 4.14 to 13.78); p < 0.001) were predictors of operative management. The median length of stay was 15 days (IQR 9 to 23), 12-month reoperation rate was 5.6% (n = 30), and 30-day readmission rate was 8.4% (n = 45). The 30-day and 12-month mortality rates were 5.2% (n = 28) and 21.0% (n = 113). Nonoperative treatment, older age, male sex, admission from residential or nursing care, and sustaining the PPF around a revision prosthesis were significant predictors of an increased 12-month mortality. Conclusion. Femoral hip PPFs have mortality, reoperation, and readmission rates comparable with hip fracture patients. However, they have a longer wait for surgery, and surgical treatment is more complex. There is a need to create a national framework for data collection for this heterogeneous group of patients in order to understand the outcomes of different approaches to treatment. Cite this article: Bone Joint J 2022;104-B(8):997–1008

Aims. Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality. Methods. Using a multicentre study design, independent of registry data, we included adult patients sustaining a PPF around a knee arthroplasty between 1 January 2010 and 31 December 2019. Univariate, then multivariable, logistic regression analyses were performed to study the impact of patient, fracture, and treatment on mortality. Results. Out of a total of 1,667 patients in the PPF study database, 420 patients were included. The in-hospital mortality rate was 6.4%. Multivariable analyses suggested that American Society of Anesthesiologists (ASA) grade, history of peripheral vascular disease (PVD), history of rheumatic disease, fracture around a loose implant, and cerebrovascular accident (CVA) during hospital stay were each independently associated with mortality. Each point increase in ASA grade independently correlated with a four-fold greater mortality risk (odds ratio (OR) 4.1 (95% confidence interval (CI) 1.19 to 14.06); p = 0.026). Patients with PVD have a nine-fold increase in mortality risk (OR 9.1 (95% CI 1.25 to 66.47); p = 0.030) and patients with rheumatic disease have a 6.8-fold increase in mortality risk (OR 6.8 (95% CI 1.32 to 34.68); p = 0.022). Patients with a fracture around a loose implant (Unified Classification System (UCS) B2) have a 20-fold increase in mortality, compared to UCS A1 (OR 20.9 (95% CI 1.61 to 271.38); p = 0.020). Mode of management was not a significant predictor of mortality. Patients managed with revision arthroplasty had a significantly longer length of stay (median 16 days; p = 0.029) and higher rates of return to theatre, compared to patients treated nonoperatively or with fixation. Conclusion. The mortality rate in PPFs around the knee is similar to that for native distal femur and neck of femur fragility fractures. Patients with certain modifiable risk factors should be optimized. A national PPF database and standardized management guidelines are currently required to understand these complex injuries and to improve patient outcomes. Cite this article: Bone Joint J 2024;106-B(2):158–165

Aims. Periprosthetic fractures (PPFs) following hip arthroplasty are complex injuries. This study evaluates patient demographic characteristics, management, outcomes, and risk factors associated with PPF subtypes over a decade. Methods. Using a multicentre collaborative study design, independent of registry data, we identified adults from 29 centres with PPFs around the hip between January 2010 and December 2019. Radiographs were assessed for the Unified Classification System (UCS) grade. Patient and injury characteristics, management, and outcomes were compared between UCS grades. A multinomial logistic regression was performed to estimate relative risk ratios (RRR) of variables on UCS grade

Aims. The aim of this study was to identify modifiable risk factors associated with mortality in patients requiring revision total hip arthroplasty (THA) for periprosthetic hip fracture. Methods. The electronic records of consecutive patients undergoing revision THA for periprosthetic hip fracture between December 2011 and October 2018 were reviewed. The data which were collected included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, the preoperative serum level of haemoglobin, time to surgery, operating time, blood transfusion, length of hospital stay, and postoperative surgical and medical complications. Univariate and multivariate logistic regression analyses were used to determine independent modifiable factors associated with mortality at 90 days and one year postoperatively. Results. A total of 203 patients were identified. Their mean age was 78 years (44 to 100), and 108 (53%) were female. The median time to surgery was three days (interquartile range (IQR) 2 to 5). The mortality rate at one year was 13.8% (n = 28). The commonest surgical complication was dislocation (n = 22, 10.8%) and the commonest medical complication within 90 days of surgery was hospital-acquired pneumonia (n = 25, 12%). Multivariate analysis showed that the rate of mortality one year postoperatively was five-fold higher in patients who sustained a dislocation (odds ratio (OR) 5.03 (95% confidence interval (CI) 1.60 to 15.83); p = 0.006). The rate of mortality was also four-fold higher in patients who developed hospital-acquired pneumonia within 90 days postoperatively (OR 4.43 (95% CI 1.55 to 12.67); p = 0.005). There was no evidence that the time to surgery was a risk factor for death at one year. Conclusion. Dislocation and hospital-acquired pneumonia following revision THA for a periprosthetic fracture are potentially modifiable risk factors for mortality. This study suggests that surgeons should consider increasing constraint to reduce the risk of dislocation, and the early involvement of a multidisciplinary team to reduce the risk of hospital-acquired pneumonia. We found no evidence that the time to surgery affected mortality, which may allow time for medical optimization, surgical planning, and resource allocation. Cite this article: Bone Joint J 2020;102-B(5):580–585

Background. As the number of primary or revision TKA with stem extension cases are growing simultaneously, the number of periprosthetic fracture in these cases has also increased accordingly. However, there have been few reports on the classification and treatment of periprosthetic fracture following stemmed TKA and lack of information about the treatment outcome. The purposes of this study were 1) to demonstrate classification and management of periprosthetic fractures after stemmed TKA and 2) to report treatment outcome after the periprosthetic fractures. Materials and Methods. This retrospective study included 17 knees (15 patients) with an average age of 69.7 years. All cases were revision TKA cases, and there were 13 female and 2 male patients. The patients were treated nonoperatively or underwent operation by orthopedic principle. The period of union was evaluated by confirming the formation of callus crossing fragments in radiographs. We reviewed the complications and functional outcomes after treatment of periprosthetic fracture following revision TKA by assessing FF, FC and scoring WOMAC and KSS. Results. The classification of periprosthetic fractures of stemmed TKA was based on location of fracture and stability of implant. They were classified as follows: type I, metaphyseal fracture without loosening of implant [Fig. 1]; type II, diaphyseal fracture adjacent to stem without loosening of implant [Fig. 2]; type III, diaphyseal fracture away from stem without loosening of implant [Fig. 3]; and type IV, metaphyseal or diaphyseal fracture with loosening of implant [Fig. 4]. There were 1 case of type I, 9 cases of type II, 4 cases of type III and 3 cases of type IV fractures. The mean time for gaining radiographic union of type I was 3.3 month; type II was 4.4 month; type III was 4.6 month; and type IV was 3.9 month. Most of the metaphyseal fractures were comminuted and all cases of loosening of the femoral implant were found in the metaphyseal fractures. Nine periprosthetic fractures were fixed using locking plate (single locking plate : 4 cases, dual locking plate : 5 cases). The bone union period is much shorter in patients with dual plate fixation than single plate only. Range of motion, WOMAC and KSS were not significantly different between before fracture and after management of fracture. Complications included 1 metal failure, 2 loosening of implant and 1 postoperative infection. Conclusions. Metaphyseal fractures probably cause the collateral ligament insufficiency, and loosen the implant. Therefore, rotating hinge prosthesis should be used to stabilize the ligament of knee joint. Also, Revision TKA with longer stem should be considered if the stability of implant is not sure. When we underwent operation using plate fixation, dual plating provided better stability of fracture and shortened the union period than single plating. However, we need to approach individually depending on the patient, such as using cerclage wire, bone graft and so on. This study will help to establish appropriate treatment options according to each classification. For any figures or tables, please contact the authors directly

The incidence of periprosthetic fractures of the ankle is increasing. However, little is known about the outcome of treatment and their management remains controversial. The aim of this study was to assess the impact of periprosthetic fractures on the functional and radiological outcome of patients with a total ankle arthroplasty (TAA). A total of 505 TAAs (488 patients) who underwent TAA were retrospectively evaluated for periprosthetic ankle fracture: these were then classified according to a recent classification which is orientated towards treatment. The outcome was evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) score and a visual analogue scale for pain, and radiologically. . A total of 21 patients with a periprosthetic fracture of the ankle were identified. There were 13 women and eight men. The mean age of the patients was 63 years (48 to 74). Thus, the incidence of fracture was 4.17%. . There were 11 intra-operative and ten post-operative fractures, of which eight were stress fractures and two were traumatic. The prosthesis was stable in all patients. Five stress fractures were treated conservatively and the remaining three were treated operatively. . A total of 17 patients (81%) were examined clinically and radiologically at a mean follow-up of 53.5 months (12 to 112). The mean AOFAS score at follow-up was 79.5 (21 to 100). The mean AOFAS score in those with an intra-operative fracture was 87.6 (80 to 100) and for those with a stress fracture, which were mainly because of varus malpositioning, was 67.3 (21 to 93). Periprosthetic fractures of the ankle do not necessarily adversely affect the clinical outcome, provided that a treatment algorithm is implemented with the help of a new classification system. . Cite this article: Bone Joint J 2015;97-B:950–6

The Unified Classification System (UCS), or Vancouver system, is a validated and widely used classification system to guide the management of periprosthetic femoral fractures. It suggests that well-fixed stems (type B1) can be treated with fixation but that loose stems (types B2 and B3) should be revised. Determining whether a stem is loose can be difficult and some authors have questioned how to apply this classification system to polished taper slip stems which are, by definition, loose within their cement mantle. Recent evidence has challenged the common perception that revision surgery is preferable to fixation surgery for UCS-B periprosthetic fractures around cemented polished taper slip stems. Indications for fixation include an anatomically reducible fracture and cement mantle, a well-fixed femoral bone-cement interface, and a well-functioning acetabular component. However, not all type B fractures can or should be managed with fixation due to the risk of early failure. This annotation details specific fracture patterns that should not be managed with fixation alone. Cite this article: Bone Joint J 2023;105-B(5):481–486

Periprosthetic femur fracture (PFF) is a major complication following total hip arthroplasty (THA) that carries significant morbidity, mortality, and economic burden. Currently, uncemented stems are highly preferred in primary THA, but have been associated with higher risk of PFF compared to cemented stems. The use of collared stems in uncemented primary THA has shown promise in reducing PFF rates postoperatively. This retrospective study included 2,294 uncemented primary THAs using the posterior approach performed by two attending surgeons from January 2016 to December 2022. Both surgeons switched from a collarless femoral stem design to a collared design in May 2020. Data was collected regarding stem design, frequency of PFF, and requirement for revision surgery. Periprosthetic fractures were identified and confirmed using medical records and/or radiographic imaging. Fracture rates and percentages between collared and collarless stems were then analyzed. A Fisher's Exact Test was performed to determine if there was a significant association between collared and collarless stem use on PFF rates. A total of 2,294 uncemented primary THAs performed by 2 surgeons were eligible for analysis. 903 (39.4%) patients received a collared stem, and 1,391 (60.6%) patients received a collarless stem. In total, 14 (0.6%) PFFs occurred over the study period. There was 1 fracture (0.1%) out of 903 collared stems, and 13 fractures (0.9%) out of 1,391 collarless stems (p = 0.012). Collared stems were associated with a significant decrease in PFF rate when compared to collarless stems in uncemented primary THA. Future studies are encouraged to continue to investigate PFF and other complication rates with the use of a collared stem design

We are currently facing an epidemic of periprosthetic fractures around the hip. They may occur either during surgery or post-operatively. Although the acetabulum may be involved, the femur is most commonly affected. We are being presented with new, difficult fracture patterns around cemented and cementless implants, and we face the challenge of an elderly population who may have grossly deficient bone and may struggle to rehabilitate after such injuries. The correct surgical management of these fractures is challenging. This article will review the current choices of implants and techniques available to deal with periprosthetic fractures of the femur. Cite this article: Bone Joint J 2014;96-B(11 Suppl A):48–55

Introduction: Management of periprosthetic fractures following total hip arthroplasty (THA) represents a difficult clinical problem, requiring expertise in both trauma and revision surgery. Estimates of the prevalence of postoperative fracture range from 0.1% to 2.1%, and with rising numbers of patients in the population living with hip prostheses in situ there is evidence that their frequency is increasing. There remains a paucity of data on the functional outcome of these injuries, and the objective of this study was to analyse outcomes for revision THA following periprosthetic fracture, and compare these to elective revision surgery. Methods: 233 patients (234 hips) undergoing revision THA for femoral fracture were identified from the New Zealand National Registry, and clinical outcomes were measured using Oxford Hip Scores (OHS) completed six months post operatively. A control group of 234 patients undergoing elective revision THA was selected and matched for age, sex, and time since index operation. Results: Comparative analysis of the registry patients showed clinical outcomes were significantly worse following revision THA for fractured femur than in controls (mean OHS 28.6 vs 23.6, p=0.006), though this difference was not apparent in patients under the age of 65 years (mean OHS 26.1 vs 23.8, p =0.6). A higher mortality rate was found among fracture patients (17.1% versus 10.7 %, p=0.05), and a statistically significant higher number of periprosthetic fracture patients died within 6 months of their surgery in comparison to controls (7.3% versus 0.9%, p=0.003). A higher rate of re-revision was observed in the fracture group (7.7% versus 2.6%, p=0.02). Conclusions: To our knowledge this study represents the largest comparative series of periprosthetic fractures in THA with functional outcome data yet reported. Management of patients with periprosthetic fractures requires recognition of the challenging nature of these injuries, their associated poor prognosis, and high complication rate

Aims. Periprosthetic fractures (PPFs) around cemented taper-slip femoral prostheses often result in a femoral component that is loose at the prosthesis-cement interface, but where the cement-bone interface remains well-fixed and bone stock is good. We aim to understand how best to classify and manage these fractures by using a modification of the Vancouver classification. Methods. We reviewed 87 PPFs. Each was a first episode of fracture around a cemented femoral component, where surgical management consisted of revision surgery. Data regarding initial injury, intraoperative findings, and management were prospectively collected. Patient records and serial radiographs were reviewed to determine fracture classification, whether the bone cement was well fixed (B2W) or loose (B2L), and time to fracture union following treatment. Results. In total, 47 B2W fractures (54.0%) and one B3 fracture (1.1%) had cement that remained well-fixed at the cement-bone interface. These cases were treated with cement-in-cement (CinC) revision arthroplasty. Overall, 43 fractures with follow-up united, and two patients sustained further fractures secondary to nonunion and required further revision surgery. A total of 19 B2L fractures (21.8%) and 19 B3 fractures (21.8%) had cement that was loose at the cement-bone interface. These cases were managed by revision arthroplasty with either cemented or uncemented femoral components, or proximal femoral arthroplasty. One case could not be classified. Conclusion. We endorse a modification of the original Vancouver system to include a subclassification of B2 fractures around cemented femoral prostheses to include B2W (where cement is well-fixed to bone) and B2L (where the cement is loose). Fractures around taper-slip design stems are more likely to fracture in a B2W pattern compared to fractures around composite beam design stems which are more likely to fracture in a B2L pattern. B2W fractures can reliably be managed with CinC revision. Cite this article: Bone Joint J 2021;103-B(1):71–78

The Lubinus SP II is an anatomical femoral stem with high survivorship levels notably described in the Swedish Arthroplasty Register. As the clinical and economic burden of revision total hip arthroplasty (THA) and periprosthetic fracture (PPF) continues to increase, it has been suggested that use of anatomical stems may facilitate more uniform cement mantles and improve implant survival. The primary aim of this study was to determine the long-term survivorship and PPF rate of the Lubinus SP II 150mm stem in a single UK centre. Between January 2007 and April 2012, 1000 consecutive THAs were performed using the Lubinus SP II femoral stem in our institution. Patient demographics and operative details were collected in a prospective arthroplasty database. Patient records and national radiographic archives were then reviewed at a mean of 12.3 years (SD 1.3) following surgery to identify occurrence of subsequent revision surgery, dislocation or periprosthetic fracture. Mean patient age at surgery was 69.3 years (SD 10.1, 24–93 years). There were 634 women (63%). Osteoarthritis was the operative indication in 974 patients (97%). There were 13 revisions in total (4 for recurrent dislocation, 3 for infection, 6 for acetabular loosening) and 16 dislocations (1.6%). Stem survivorship at 10 years was 99.6% (95 % confidence interval [CI], 99.5%–99.7%) and at 15 years was 98.8% (98.7%–98.9%). The 15-year stem survival for aseptic loosening was 100%. Analysis of all cause THA failure demonstrated a survivorship of 99.1% (99.0%–99.3%) at 10 years and 98.2% (98.1%–98.3%) at 15 years. There were 4 periprosthetic fractures in total (0.4%) at mean 12.3 year follow-up. The Lubinus SP II stem demonstrated excellent survivorship, low dislocation rates and negligible PPF rates up to 15 years following primary THA. Use of anatomical stems such as the Lubinus SPII would appear to be a wise clinical and economic investment for patients and healthcare systems alike

Fractures around total knee arthroplasties pose a significant surgical challenge. Most can be managed with osteosynthesis and salvage of the replacement. The techniques of fixation of these fractures and revision surgery have evolved and so has the assessment of outcome. This specialty update summarises the current evidence for the classification, methods of fixation, revision surgery and outcomes of the management of periprosthetic fractures associated with total knee arthroplasty. Cite this article: Bone Joint J 2016;98-B:1489–96

Background. Periprosthetic femoral fractures following total hip arthroplasty are relatively uncommon but are associated with significant morbidity. With an increasing number of total hip arthroplasties being carried out in an aging population we need to ensure correct implants are chosen for our patients. A recent review of NJR data suggested a significantly higher revision risk for the Zimmer CPT stems due to periprosthetic fractures when compared to the Stryker Exeter stems. Objectives. Our aim was to compare the biomechanics of periprosthetic fractures around the CPT and Exeter V40 stems in a composite saw bone model to identify if a difference in fracture risk exists between the two stems. We also compared the engineering design of the two implants in order to analyse the possible effect this may have on fracture risk. Study Design & Methods. Fourteen composite femurs were divided into two groups and cemented using Palacos R cement with either the CPT or Exeter V40 stem by a single surgeon. The implanted femurs were then mounted onto an Instron machine and were axially loaded and torqued to fracture with an axial compressive force of 2000N over 10 seconds followed by a rotation of 40 degrees applied over 1 second. A power calculation from a previous composite saw bone model study suggested that a minimum of 6 implanted femurs would be required in each group. Results. The implanted femurs invariably sustained fracture patterns similar to the Vancouver B2 periprosthetic fracture which are commonly seen in clinical practice. Implanted femurs with CPT stems suffered periprosthetic fractures with less rotation when compared to those femurs with the Exeter V40 stem (20.10 versus 33.60, p<0.01). We also found that CPT implanted femurs were fracturing at significantly lower torque values when compared to the Exeter V40 implanted femurs (124Nm Versus 174Nm, p<0.01). The energy release rate (G111) for CPT stems was 21.8Nm compared to 61.2Nm for Exeter V40 stems. The higher energy release with Exeter stems led to more comminuted fractures in Exeter implanted femurs when compared to the CPT femurs, which fractured earlier, but with simpler fracture patterns. Finite element method (FEM) simulation analysis showed that fractures initiated between the prosthesis and cement at the proximal end of the femur. Two dimensional sections at the same height showed a difference in bone-cement-implant geometrics at the critical point of failure suggesting that a design cause may be the reason for the higher risk of periprosthetic fractures in CPT implanted femurs. Conclusions. Our observations may explain the higher revision risk secondary to periprosthetic fractures that has been observed with the CPT stem when compared to the Exeter V40 stem

Introduction: The amount of tension which surgeons apply to a two-side Dall-Miles cable during the fixation of periprosthetic fracture has not been reported. Current study is the first report that reveals the real cable tension data which was intraoperatively measured. Methods: In vivo data of tightening torque was measured intraoperatively during Dall-Miles cable fixation surgeries for periprosthetic fracture of the femur. And the numerical relationship between torque and cable tension was assessed through mechanical tests. Using the torque vs. cable tension relationship, intraoperatively measured tightening torque was converted into a cable tension. Intraoperative measurement of tightening torque In vivo data of the maximal torque which was applied by an experienced surgeon was measured using a torquemeter. Total 11 cases of periprosthetic femoral fractures from 11 patients were participated with their agreement. A two-side Dall-Miles cable tightener (Stryker Co., USA) was used. To measure the torque of Dall-Miles tightener applied by a surgeon, a torquemeter (Torque driver 80FTD2-N-S, TOHNICHI, JAPAN) was connected to the Dall-Miles tightener through a square groove. The groove was machined with 1cm × 1cm × 1cm in dimension on the proximal end of the rotational shaft of the Dall-Miles tightener. Laboratory measurement of torque and tension To reveal the relationship between the torque of Dall-Miles cable tensioner and the tension of the cable, mechanical tests were done. A two-side Dall-Miles cable tightener were mounted to INSTRON (INSTRON, Norwood, MA, USA) using a customized fixation jig. One cable of 2 mm in diameter was connected to the upper head of INSTRON, and another to the lower headA preload was slowly applied to the cables up to 10 N so that the initially loose interaction among a tightener, two cables, and two loading heads of INSTRON became tight. Once the preloading finished, tightening torque and cable tension were simultaneously measured. The tightening torque was increased in increment of 1 N-m; accordingly, at each torque the tension hung to Dall-Miles cable was measured by reading loadcell data of INSTRON. Results: Intraoperative tightening torque Intraoperatively measured maximal torque applied to the Dall-Miles cable tensioner was 5.7±0.5 N-m. Numerical expression of torque-tension relationship Based on the data of tightening torque and cable tension measured from mechanical tests, the relationship between the torque (T) and tension (P) of Dall-Midles cable fixation system was numerically expressed. Total range of measured tightening torques and cable tensions was linearized. The linear expression was “T=106.8 × P”. Based on this numerical relationship, the amount of cable tension applied to the cable was calculated as 606.6±58 N. Discussion: This study revealed that 606.6±58 N of cable tension has been applied when an experienced surgeon does cable fixation of periprosthetic fracture. Authors believe that the torque-tension relationship will provide a key biomechanical clue for biomechanics scientists, and the amount of intraoperative cable tension measured at the time of Dall-Miles cable fixation for periprosthetic fracture will provide an important surgical key reference for the surgeons who use the cable fixation system

Mortality following revision hip surgery for periprosthetic fracture (PPF) has been reported to be as high as 60% at 5 years. The aim of this study was to determine the mortality rate for PPF revisions, compared to revision for aseptic loosening or infection at our tertiary referral centre. Revision arthroplasty procedures performed for PPF, aseptic loosening or infection between January 2014 and December 2015 at our institution were identified using a prospectively collected PPF referral database and locally collected NJR data. Comparisons were made between the 3 groups for baseline demographics, admission to higher-level care, length of stay, complications, and Kaplan-Meier failure (mortality) at 1 & 5 years post-operative (with log-rank test for equality). There were 37 PPF, 71 infected and 221 aseptic revisions. PPF had a higher proportion of females (65% vs. 39% in infection and 53% in aseptic; p = 0.031) and grade 3 and 4 ASA patients (p = 0.006). Median time to surgery from injury for PPF was 8 days (95% CI, 6–16). Single-stage procedures were performed in 84% of PPF, 42% of infection and 99% of aseptic revisions (p < 0.001). 19% of PPF revisions required HDU admission, 1% in the aseptic group and none in the infection group (p<0.001). Median length of stay was significantly different (PPF 10; infection 14; aseptic 8 days (p < 0.001). The Kaplan-Meier estimate of 1-year mortality were: PPF = 0%; infection = 2.8% (0.7–11.1%); aseptic = 0.9% (0.2–3.5%). 5-year mortality estimates were: PPF = 17.1% (8–34%), infection = 8.7% (4–18.3%), aseptic = 12% (8.4–17%). Log-rank test of equality was not significant, p=0.833. Despite the PPF group having an average delay to surgery of 8 days, higher ASA grades and more admissions to HDU there was no significant difference in mortality rates between the groups at 1 and 5 years postoperatively. Using a coherent MDT approach with dedicated healthcare professionals this service demonstrates a low post operative mortality rate which merits further investment and development

Aims. The aim of this study was to identify patient- and surgery-related risk factors for sustaining an early periprosthetic fracture following primary total hip arthroplasty (THA) performed using a double-tapered cementless femoral component (Bi-Metric femoral stem; Biomet Inc., Warsaw, Indiana). Patients and Methods. A total of 1598 consecutive hips, in 1441 patients receiving primary THA between January 2010 and June 2015, were retrospectively identified. Level of pre-operative osteoarthritis, femoral Dorr type and cortical index were recorded. Varus/valgus placement of the stem and canal fill ratio were recorded post-operatively. Periprosthetic fractures were identified and classified according to the Vancouver classification. Regression analysis was performed to identify risk factors for early periprosthetic fracture. Results. The mean follow-up was 713 days (1 to 2058). A total of 48 periprosthetic fractures (3.0%) were identified during the follow-up and median time until fracture was 16 days, (interquartile range 10 to 31.5). Patients with femoral Dorr type C had a 5.2 times increased risk of post-operative periprosthetic fracture compared with type B, while female patients had a near significant two times increased risk over time for post-operative fracture. Conclusion. Dorr type C is an independent risk factor for early periprosthetic fracture, following THA using a double tapered cementless stem such as the Bi-Metric. Surgeons should take bone morphology into consideration when planning for primary THA and consider using cemented femoral components in female patients with poor bone quality. Cite this article: Bone Joint J 2017;99-B:451–7

Periprosthetic fracture of the femur is an uncommon complication after total hip replacement, but appears to be increasing. We undertook a nationwide observational study to determine the risk factors for failure after treatment of these fractures, examining patient- and implant-related factors, the classification of the fractures and the outcome. Between 1979 and 2000, 1049 periprosthetic fractures of the femur were reported to the Swedish National Hip Arthroplasty Register. Of these, 245 had a further operation after failure of their initial management. Data were collected from the Register and hospital records. The material was analysed by the use of Poisson regression models. It was found that the risk of failure of treatment was reduced for Vancouver type B2 injuries (p = 0.0053) if revision of the implant was undertaken (p = 0.0033) or revision and open reduction and internal fixation (p = 0.0039) were performed. Fractures classified as Vancouver type B1 had a significantly higher risk of failure (p = 0.0001). The strongest negative factor was the use of a single plate for fixation (p = 0.001). The most common reasons for failure in this group were loosening of the femoral prosthesis, nonunion and re-fracture. It is probable that many fractures classified as Vancouver type B1 (n = 304), were in reality type B2 fractures with a loose stem which were not recognised. Plate fixation was inadequate in these cases. The difficulty in separating type B1 from type B2 fractures suggests that the prosthesis should be considered as loose until proven otherwise

Periprosthetic femoral fractures can occur as a complication of total hip arthroplasty and are often challenging to treat as the mechanical scenario is influenced by the presence of the metal prosthesis within the bone. This research focuses on finding the optimum fixation for transverse, Vancouver type B1 periprosthetic fractures, stabilised using locking plates and secured using screws. The aim of this study was to experimentally validate a computer model of a human femur, develop that model to represent a periprosthetic femoral fracture fixation and show how the model could be used to indicate differences between plating techniques. In the first development stage, both a laboratory model and a finite element model were developed to evaluate the mechanical behaviour of an intact composite femur under axial loading. Axial strains were recorded along the medial length of the femur in both cases and compared to provide validation for the computational model predications. The computational intact femur model was then modified to include a cemented total hip replacement, and further adapted to include a periprosthetic fracture stabilised using a locking plate, with unicortical screws above, and bicortical screws below the transverse fracture. For the intact femur case, the experimental and computational strain patterns correlated well with an average difference of 16%. Following the inclusion of the stem, there was a reduction in the strain in the region of the prosthesis reducing by an average of 45%. There was also a large increase in bulk stiffness with the introduction of the prosthesis. When the fracture and plate fixation were included, there was little difference in the proximal strain where the stem dominated, and the strains in the distal region were found to be highly sensitive to the distribution of the screws. The results of this study indicate that screw configuration is an important factor in periprosthetic fracture fixation. A laboratory model of the periprosthetic facture case is now under development to further validate the computational models and the two approaches will then be used to determine optimum fixation methods for a range of clinical scenarios

Introduction and Aims: Periprosthetic fracture is a serious complication of increasing incidence in joint replacement. Our aim was to evaluate periprosthetic fracture patterns in our series of 1152 primary hip arthroplasties using a cementless proximally hydroxyapatie coated anatomic stem and to identify risk factors from parameters measured in our assessment of these patients. Method: All patients with periprosthetic fracture following primary total hip arthroplasty using the Anatomique Benoist Girard I (ABG I) hip system were identified. Parameters studied included time of fracture after surgery, patient age and fracture classification. The pre-operative cortical index in the fracture group was measured and compared with a group matched for age, gender, diagnosis, and body mass index. 1152 ABG I primary hip arthroplasties were performed in 1037 patients from 1991–1997. Osteoarthritis was diagnosed in 93% of cases. The average age was 65 years; there were 536 females and 501 males. Mean follow-up was 79.6 months. Results: Thirty-two patients, 16 male and 16 female, suffered a periprosthetic fracture. Thirty-one patients were treated for osteoarthritis and one for a femoral neck fracture. We retrieved complete records on 28 patients. The average age of the fracture group was 73 years, compared to 65 years for the whole series (p< 0.0001). The incidence of periprosthetic fracture increased with age. The relative risk for patients over 70 years for peri-prosthetic fracture is 4.7 greater (95% CI 2.14–10.21). Distinct fractures patterns were related to time from initial surgery. Four fractures occurred within three months of surgery; these early fractures exhibited a particular pattern. The remaining 24 occurred between four and 114 months after surgery. These late fractures exhibited a different but consistent fracture pattern. Two fractures in the early group were identified immediately post-operatively. All others presented after minor low energy trauma. The mean cortical index in the fracture group was 47% and in the matched group 51%. If the pre-operative cortical index is below 50%, the risk of periprosthetic fracture is 4.75 greater (odds ratio 4.75 CI 1.5–15.00). All fractures were adequately classified and managed by guidelines in the Vancouver classification. Conclusion: This study identified distinct fracture patterns related to time from surgery. Cortical index and age have predictive value in pre-operative assessment of fracture risk: cortical index below 50 and age above 70 are risk factors for periprosthetic fracture and should be considered with other parameters to minimise risk of this complication

PURPOSE OF STUDY. Periprosthetic fractures after total knee arthroplasty is a potentially serious and challenging complication and the incidence is continuously rising. The purpose of this study was to analyse the prevalence and analyse effectiveness of the various treatment methods for management of periprosthetic fracture of the distal femur after total knee arthroplasty, and to determine the clinical and radiographic results of patients following surgical treatment of these injuries. METHODS. We reviewed all patients with periprosthetic fractures after total knee arthroplasty treated surgically between 2003 and 2008 from the prospective hospital database. Medical and radiographic records were reviewed for patient characteristics, fracture characteristics, implant details, healing, and complications. Antero-posterior and lateral radiographs were reviewed at the time of admission, post-operatively and at follow up visits. Fractures were classified according to the Lewis and Rorabeck, Orthopaedic Trauma Association and the methods of Su and DeWal. RESULTS. 26 patients (average age= 77.6) had operative management for displaced fractures. Mechanical fall was the commonest mode of injury at a mean of 4.66 years post primary replacement. Locking plates was the commonest method of fixation for stable implant and displaced fractures [Lewis & Rorabeck type 2] and 2 patients had distal femoral replacements for unstable implants. Successful fracture healing within 6 months occurred in all but one patient. Full weight bearing mobilisation was achieved at 3 months in 94% and patients with distal femoral replacements achieved quickest recovery. CONCLUSIONS. Compared to the current literature, we had a satisfactory outcome in following individualised treatment of periprosthetic fractures after knee joint replacement. Periprosthetic femoral fractures around the knee commonly constitute a challenging problem and require an adequate analysis of fracture etiology and distal femoral replacement achieves satisfactory results in fractures with unstable implants

Aims. The aim of this large registry-based study was to compare mid-term survival rates of cemented femoral stems of different designs used in hemiarthroplasty for a fracture of the femoral neck. Patients and Methods. From the Norwegian Hip Fracture Register (NHFR), 20 532 primary cemented bipolar hemiarthroplasties, which were undertaken in patients aged > 70 years with a femoral neck fracture between 2005 and 2016, were included. Polished tapered stems (n = 12 065) (Exeter and CPT), straight stems (n = 5545) (Charnley, Charnley Modular, and Spectron EF), and anatomical stems (n = 2922) (Lubinus SP2) were included. The survival of the implant with any reoperation as the endpoint was calculated using the Kaplan–Meier method and hazard ratios (HRs), and the different indications for reoperation were calculated using Cox regression analysis. Results. The one-year survival was 96.0% (95% confidence interval (CI) 95.6 to 96.4) for the Exeter stem, 97.0% (95% CI 96.4 to 97.6) for the Lubinus SP2 stem, 97.6% (95% CI 97.0 to 98.2) for the Charnley stem, 98.1% (95% CI 97.3 to 98.9) for the Spectron EF stem, and 96.4% (95% CI 95.6 to 97.2) for the Charnley Modular stem, respectively. The hazard ratio for reoperation after one year was lower for Lubinus SP2 (HR 0.77, 95% CI 0.60 to 0.97), Charnley (HR 0.64, 95% CI 0.48 to 0.86), and Spectron EF stems (HR 0.44, 95% CI 0.29 to 0.67) compared with the Exeter stem. Reoperation for periprosthetic fracture occurred almost exclusively after the use of polished tapered stems. Conclusion. We were able to confirm that implant survival after cemented hemiarthroplasty for a hip fracture is high. Differences in rates of reoperation seem to favour anatomical and straight stems compared with polished tapered stems, which had a higher risk of periprosthetic fracture

Purpose of the study: Few data are available concerning the proper management of patients with a periprosthetic fracture of the hip who presents biological signs of inflammation (increased WBC, sedimentation rate, or C-reactive protein). The purpose of this work was to determine the prevalence of elevated biological markers in this type of patient and to determine the reliability of such markers for the diagnosis of periprosthetic infection. Material and methods: A periprosthetic hip fracture was diagnosed in 204 patients from 2000 to 2006. The WBC count, the sedimentation rate and the serum CRP level were noted at admission to the emergency ward. The diagnosis of infection was confirmed by at least two positive bacteriological samples of tissue biopsy and/or joint fluid collected at surgery. A statistical analysis was conducted to determine the prevalence of elevated biological markers of inflammation, the sensitivity, their specificity and their positive predictive value for deep infection. Results: Twenty-one patients (11.6%) developed a periprosthetic infection. Among the 204 patients, the WBC count increased in 16.2%, sedimentation rate in 33.3% and CRP in 50.5%. The sensitivity was 24% (WBC), 50% (sedimentation rate) and 83% (CRP). The specificity was 85% (WBC), 69% (sedimentation rate) and 56% (CRP). The positive predictive value was low (18, 21 and 29% respectively). Discussion: Markers of inflammation are frequently ordered before surgery to search for infection but can be elevated for various reasons. Most often, these markers are elevated because of the patient’s general status and are thus related to other co-morbid conditions and/or reaction to the new fracture. In this population, the WBC count did not contribute to the diagnosis of infection as only 24% of the infected patients had a high count. CRP and sedimentation rate and the WBC count had low positive predictive values. Conclusion: This study shows that an isolated elevation of biological markers of inflammation in a patient with a periprosthetic fracture is not a good indicator of infection

Periprosthetic fractures present an increasing workload as more hip arthroplasties are performed. They are often challenging to treat due to poor bone stock and patient frailty. We compare the early clinical and radiological results in 2 centres of 24 consecutive periprosthetic hip fractures in 24 patients, using a cannulated interlocked long stemmed titanium alloy femoral component with or without a hydroxyapatite (HA) coating (Cannulok revision prosthesis). The mean age at the time of operation was 79 years (range 65 to 92.4 years). The average length of follow up was 1.17 years (range 3 months to 5.3 years). All patients receiving a Cannulok revision stem with a minimum follow up of 3 months were included regardless of their primary aetiology and number of previous surgical procedures. Patients were reviewed and scored using the Merle d’Aubigne and Postal Score, Harris Hip Score and the WOMAC index at latest review. Periprosthetic fractures were classified using the Vancouver classification. At latest radiological review we measured subsidence, new bone formation (including presence of callus), osteolysis and radiolucent lines in all areas of the stem. Of the 24 fractures, 22 healed. In the 14 who had HA coated implants there was a 50% increase in bone. In the non-HA coated stems there was a 36% increase in bone radiologically. The mean Harris hip score was 74 at the latest post-operative review. The mean WOMAC and MDP scores were 48.7 and 7.7 respectively. The mean pain visual analogue score was 1.6 overall and 0 specifically for mid-thigh pain. We present encouraging early clinical and radiological results of the Cannulok stem system for treatment of complex periprosthetic fractures. This implant provides early fracture stability and subsequent biological bonding with an improvement in bone mass

We present a case of multifocal infection involving the left total hip replacement and the right total knee replacement of a patient, further complicated by an infected non-union of a periprosthetic fracture of the right knee. This required the unique simultaneous management of both infection eradication and fracture stabilization in the knee. Both sites were treated with a 2-stage procedure, including the novel use of a stemmed articulating spacer for the right knee. This spacer was made combining a retrograde humeral nail, coated with antibiotic-impregnated cement, and a pre-formed articulating cement spacer. The patient was able to weight-bear on this spacer. The fracture went on to unite, and a second stage was performed with the use of stemmed prosthesis and augments. She remains infection free 2 years after the second stage operation. The use of a stemmed articulating knee spacer can facilitate infection eradication and fracture stabilization while preserving some motion and weight-bearing ability in the 2 stage management of an infected periprosthetic fracture of the knee

Post-operative periprosthetic fracture of the femur (POPFF) is a growing problem associated with increased mortality. Most registry derived estimates of mortality only record patients who undergo revision and cohort studies are generally limited to a single center, which makes comparison for the purposes of service improvement difficult. The aim of this study is to perform a systematic review and meta-analysis of cohort studies reporting mortality following POPFF in the last decade. Study methodology was peer-reviewed (PROSPERO: CRD42020170819). Literature search was conducted using Medline and EMBASE. Primary exposure was the diagnosis of POPFF, and the primary outcome measure was all-cause mortality: whilst an inpatient, within 30-days, within 90-days and within one year of POPFF. Proportion of patients dying (95% CI [confidence interval]) was estimated using metaregression. Results were compared to mortality following neck of femur fracture (NOF) from international NOF registry data. 4841 patients from 35 cohort studies were included. Study quality was generally low with a majority limited to a single centre. Weighted mean follow-up was 2.3 years and the most common POPFF was UCS B. Pooled proportion dying as an inpatient was 2.4% (95% CI 1.6% to 3.4%). Pooled proportion dying within 30 days was 3.3% (95% CI 2.0% to 5.0%). Pooled proportion dying within 90 days was 4.8% (95% CI 3.6% to 6.1%). Pooled proportion dying within one year was 13.4% (95% CI 11.9% to 14.8%). Mortality following POPFF was similar to that of NOF up to 30 days, but better at one year. 3.3% of patients die following POPFF within 30 days of injury. Mortality is similar to that experienced by patients following NOF up to 30 days, but better at one year, which may represent the lower underlying risk of death in the POPFF cohort. These results may form the basis for evaluation of services treating POPFF in the future

Aim. Periprosthetic fractures are usually observed in patients aged over 65 years. The incidence of postoperative periprosthetic femur and tibia fractures is rising with increasing number of hip and knee joint replacements and the increasing life expectancy. The aetiology of periprosthetic fractures is multifactorial. Minimal trauma is causal for the fracture in most cases. Other risk factors are: generalized osteoporosis, loosening of the prosthesis and revision arthroplasty. Our aim is restoration of the patient's pre-fracture functional status. Method. Between 2004 and 2009 in the Asklepios Orthopedic Clinic Hohwald 118 patients (82 women, 36 men) were operated because of periprosthetic fractures. Mean patient age at surgery was 71 years (range 60-87). The right treatment depends on the location of the fracture and the stability of the implant. Very important is also the quality of bone and the patient's general state of health. Results. A successful surgical treatment requires a careful preoperative planning. The type of the fracture with or without prostheses instability and with or without bone defect all have influence on the type of patients surgery. Two patients died within one year. There were 2 cases of infection and cases of 5 late healing. Fixation with different plates was used for 67 fractures, at intact and undamaged endoprosthesis was used usually osteosynthesis with “Less Invasive Stabilisation System” plate (LISS, NCB). It combines high primary stability with the biological advantages of a slide-insertion plate osteosynthesis. Retrograde nailing was possible in 5 patients and 8 further with screws and cerclage wiring. In 38 cases we changed the endoprosthesis partially or completely. We reconstructed prosthetic damage or periprosthetic fractures with bone defect using modular prostheses. This system allows a large number of additional components and their combination with cone blocks for reconstruction of severe bone defects. Conclusion. Periprosthetic fractures have such a range of clinical presentations that they need to be managed on individual basis. The best functional results for stable implants gived internal fixation with a plate. Alternative osteosynthetic techniques and additive minimal osteosynthesis can work better in special cases. Modular prostheses for bone replacement are a method of choice for fractures with extensive bone loss. Nonoperative treatment should only be performed in exceptional cases. Periprosthetic fractures are serious complications because of the mortality and the difficulty in achieving functional recovery after treatment. Our primary aim is remobilization as early as possible-that is the best prevention of secondary complications

Aims. Periprosthetic fracture (PF) after primary total hip arthroplasty (THA) is an uncommon but potentially devastating complication. This study aims to investigate the influence of cemented stem designs on the risk of needing a revision for a PF. Patients and Methods. We analysed data on 257 202 primary THAs with cemented stems and 390 linked first revisions for PF recorded in the National Joint Registry (NJR) of England, Wales and Northern Ireland to determine if a cemented femoral stem brand was associated with the risk of having revision for a PF after primary THA. All cemented femoral stem brands with more than 10 000 primary operations recorded in the NJR were identified. The four most commonly used cemented femoral stems were the Exeter V40 (n = 146 409), CPT (n = 24 300), C-Stem (n = 15 113) and Charnley (n = 20 182). We compared the revision risk ratios due to PF amongst the stems using a Poisson regression model adjusting for patient factors. Compared with the Exeter V40, the age, gender and ASA grade adjusted revision rate ratio was 3.89 for the cemented CPT stem (95% confidence interval (CI) 3.07 to 4.93), 0.89 for the C-Stem (95% CI 0.57 to 1.41) and 0.41 for the Charnley stem (95% CI 0.24 to 0.70). Conclusions. The limitations of the study include incomplete data capture, analysis of only PF requiring revision and that observation does not imply causality. Nevertheless, this study demonstrates that the choice of a cemented stem may influence the risk of revision for PF. Cite this article: Bone Joint J 2016;98-B:1347–54

The use of plate-and-cable constructs to treat periprosthetic fractures around a well-fixed femoral component in total hip replacements has been reported to have high rates of failure. Our aim was to evaluate the results of a surgical treatment algorithm to use these lateral constructs reliably in Vancouver type-B1 and type-C fractures. The joint was dislocated and the stability of the femoral component was meticulously evaluated in 45 type-B1 fractures. This led to the identification of nine (20%) unstable components. The fracture was considered to be suitable for single plate-and-cable fixation by a direct reduction technique if the integrity of the medial cortex could be restored. Union was achieved in 29 of 30 fractures (97%) at a mean of 6.4 months (3 to 30) in 29 type-B1 and five type-C fractures. Three patients developed an infection and one construct failed. Using this algorithm plate-and-cable constructs can be used safely, but indirect reduction with minimal soft-tissue damage could lead to shorter times to union and lower rates of complications

Periprosthetic fracture of the femur after hip arthroplasty is a difficult problem. Management depends on different clinical factors and these are fractures are managed at District General Hospitals. Present series is of fifty such fractures presenting between 1999 and 2004 in two District General Hospitals in England. Number of female patients were more than males and majority of patients sustained these injuries after trivial fall. Outcome of management are analysed according to modified ‘Tower and Beals’ criteria (1999). Eleven patients lost to follow-up, twelve patients died (mortality was twenty-four percent) during follow-up. Twenty-one patients progressed to clinical and radiological union at an average of eight and eleven months respectively. Six patients are under follow-up. Although several results are published in literature but the present result is comparable to the most literatures. If certain principles are followed comparable results can be obtained in District General Hospitals by Surgeons with a special interest in the management of these fractures

Aims

The aim of this study was to determine both the incidence of, and the reoperation rate for, postoperative periprosthetic femoral fracture (POPFF) after total hip arthroplasty (THA) with either a collared cementless (CC) femoral component or a cemented polished taper-slip (PTS) femoral component.

Introduction: The JRI Furlong HAC LOL hemiarthroplasty stem has shown increased periprosthetic fracture rates compared to previous literature(15.2% vs 7.4%). This study will seek to identify a measurable radiographic index, the Metaphyseal-Diaphyseal Index (MDI) score to determine whether intra-operative fracture in osteoporotic bone can be predicted to influence the type of prosthesis used (cemented or uncemented). Methodology: Over 5 years prospectively, a cohort of 560 consecutive patients undergoing hemiarthroplasty (cemented and uncemented) were evaluated. Clinical outcomes and radiographic analysis was performed. The Vancouver Classification was used to classify peri-prosthetic fracture. The MDI score was calculated using radiographs from the uncemented group. As a control (gold standard), Yeung et al’s CBR score was also calculated. From this, a receiver operating characteristic (ROC) curve was formulated for both scores and area under the curve (AUC) compared. Intra and inter-observer correlations were determined. Cost analysis was also worked out for adverse outcomes. Results: 407 uncemented and 153 cemented stems were implanted. 62 periprosthetic fractures occurred in the uncemented group (15.2%), 9 occurred in the cemented group (5.9%), p< 0.001. The revision rate for sustaining a periprosthetic fracture (uncemented group) was 17.7%, p< 0.001. MDI’s AUC was 0.985 compared to CBR’s 0.948, p< 0.001. The MDI score cut-off to predict fracture was 21, sensitivity 98.3%, specificity 99.8%, positive predictive value 90.5% and negative predictive value 98%. ANCOVA analysis ruled out any other confounding factors as being significant. The intra and inter-observer Pearson correlation scores were r=0.99, p< 0.001. The total extra cost due to the intra-operative fractures was ú40,140. Discussion: The MDI score has been shown to be a potentially useful, cost effective way of preventing this serious complication from occurring. We recommend that any femur scoring 21 or less on the MDI score be considered for cemented hemiarthroplasty. Level of evidence: Level 2 Diagnostic Study: Investigating a diagnostic test against gold standard

Aims

Periprosthetic femoral fracture (PPF) is a major complication following total hip arthroplasty (THA). Uncemented femoral components are widely preferred in primary THA, but are associated with higher PPF risk than cemented components. Collared components have reduced PPF rates following uncemented primary THA compared to collarless components, while maintaining similar prosthetic designs. The purpose of this study was to analyze PPF rate between collarless and collared component designs in a consecutive cohort of posterior approach THAs performed by two high-volume surgeons.

Dual mobility (DM) is most often used by surgeons to reduce instability in high risk patients. NJR data on DM has not demonstrated a reduction in all cause revision and has reported an increase in revision for peri-prosthetic fracture (PPF). The aim of our study was:

Prospective F/U of a DM implant since 2016 and enrolled into Beyond Compliance (BC). Primary outcome measure all-cause revision with secondary outcome including any re-operation and Oxford Hip Score (OHS). All patients were risk stratified and considered high risk for instability. Complications were identified via hospital records, clinical coding linkage, NJR and BC. Benchmarking data for comparison was obtained from same data sources we also considered all B type PPF that occurred with cemented polished taper stem (PTS).

159 implants in 154 patients with a mean age 74.0 years and a maximum F/U of 6.7 years. Survivorship for all-cause revision 99.4% (95% CI 96.2–99.8). One femoral only revision. Mean gain in OHS 27.4. Dislocation rate 0.6% with a single event. Patients with a PTS rate of Type B PPF 2.1% requiring revision/fixation. Compared to cTHA this cohort was significantly older (74.0 vs 68.3 years), more co-morbidity (ASA 3 46.5% vs 14.4%) and more non-OA indications (32.4% vs 8.5%). Relative risks for dislocation 0.57 (95%CI 0.08–4.1) and PPF 1.75 (95%CI 0.54–5.72). Every patient had at least one risk factor for falling and >50% of cohort had 4 or more risk factors using NICE tool.

The selective use of DM in high-risk patients can reduce the burden of instability. These individuals are very different to the “average” THA patient. A “perfect storm” is created using a high-risk implant combination (DM & PTS) in high-risk falls risk population. This re-enforces the need to consider all patient and implant factors when deciding bearing selection.

Polished taper-slip (PTS) cemented stems have an excellent clinical track record and are the most common stem type used in primary total hip arthroplasty (THA) in the UK. Due to low rates of aseptic loosening, they have largely replaced more traditional composite beam (CB) cemented stems. However, there is now emerging evidence from multiple joint registries that PTS stems are associated with higher rates of postoperative periprosthetic femoral fracture (PFF) compared to their CB stem counterparts. The risk of both intraoperative and postoperative PFF remains greater with uncemented stems compared to either of these cemented stem subtypes. PFF continues to be a devastating complication following primary THA and is associated with high complication and mortality rates. Recent efforts have focused on identifying implant-related risk factors for PFF in order to guide preventative strategies, and therefore the purpose of this article is to present the current evidence on the effect of cemented femoral stem design on the risk of PFF.

Cite this article: Bone Joint J 2024;106-B(1):11–15.

Aims

The aim of this study was to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter).

Purpose: Periprosthetic fractures around hip prostheses are difficult problems because these fractures range from the very simple (requiring no surgical intervention) to the complex (requiring major surgery). This paper evaluates the primary stability and restoration of femoral bone stock following treatment of Vancouver type B-2 periprosthetic fracture of the femur using an extensively hydroxy-apatite coated revision stem implant. Methods: We have prospectively reviewed 9 cases with B-2 periprosthetic fracture operated at our centre between 1996 to 2001. Of the nine patients, 4 were male and 5 female. The mean age was 76.7 years (50-92). All patients were treated by femoral revision using an extensively hydroxy-apatite coated titanium revision femoral stem (Restoration HA, Stryker, Rutherford, NJ). Fixation was augmented with a combination of cerclage cables and onlay cortical strut allografts. Results: There has been no loss to follow-up. 1 patient died, but at most recent follow-up the fracture had united with radiological evidence of bone on-growth to the stem. Mean follow up in the rest of the cohort was 3.3 years. There was radiological evidence of fracture union in all patients. Mean subsidence of the stem was 0.22mm. At most recent follow-up the mean Harris Hip Score had improved to 77.2 (63-93). Favourable bone remodelling was observed in all patients with no evidence of stress shielding so far. At most recent follow-up there have been no cases of mechanical failure, deep infection or dislocations. No patient is awaiting further revision. Conclusion and Significance: Te Restoration HA stem has produced excellent clinical results in our study. We have observed no intra operative fracture and low postoperative complication rate. We are extremely encouraged by the observed femoral remodelling. There has been no case of mechanical failure as yet and there is no reason to expect, once union and on-growth have occurred, that loosening will be a problem. In treating this challenging and increasingly common complication of total hip replacement, femoral revision using an extensively HA coated revision femoral component offers a reliable method of femoral fixation leading to successful fracture healing and early return to function

There are many management solutions for the fixation of Periprosthetic fractures with intact stem of Hip and shoulder arthroplasties. The Bio Mechanics of single plate application are unlikely to be strong enough to commence mobilisation and its effectiveness against torsional strain with an osteoporotic bone quality is of concern. Double plate fixation as discussed at the last South African Orthopaedic Congress by Mr Floyd et al is another option but this again may have some biomechanical concerns and biological compromise at the fracture site due to periosteal stripping. Implant revision with a longer stem is a bigger surgical insult to a potentially frail group of patients with questionable bone quality. We report a short series of 16 peri-prosthetic fractures with intact stem that are managed with Zimmer cable plate fixation System. The results were very satisfactory and we consider this an attractive option to be considered in the management of this difficult presentation. This is a retrospective study. We present the results of 13 Periprosthetic Femoral Shaft fractures and 3 humeral periprosthetic fractures in 16 patients treated with cable plate fixation system. Majority of the patients were over 60 years with an ASA rating of 3–4. The procedures were performed in a district general hospital in the UK between August 2001 to December 2005. The patients presented with in 1–20 years following initial Arthroplasty. All the fractures were fixed with Zimmer cable plate fixation system. An 8 hole plate was most commonly used for femoral fractures through the lateral approach for TYPE 2 fractures. The proximal end of the plate was secured with 3–4 cable ties. Early partial weight bearing was encouraged. The majority of the patients were discharged within 12 weeks. Of the 3 humeral fractures union was achieved at 12 weeks in 2. There was 1 case of implant failure due to a further fracture noted in a manic depressive patient, who was not compliant. All proximal femoral fractures showed evidence of clinical and radiological union by 6 months. The majority (7/13) had united within 20 weeks. There were no complications noted. We recommend this effective method should seriously be considered in the management of this difficult and increasingly occurring complication in a frail population

Early failure of metal-on-metal (MoM) total hip replacements (THR) is now well established. We review 93 consecutive patients with CPT¯ stems MoM THR. Our series demonstrates a new mechanism of failure, which may be implant combination specific. Between January 2005 and June 2009, 93 consecutive MoM total hip replacements were preformed using CPT stems by 3 surgeons at our unit. 73 CPT¯ stems, Metasul¯ Large Diameter Heads (LDH) with Durom¯ acetabulae and 20 CPT¯ stems, Metasul¯ 28mm diameter heads in Allofit¯ shells (zimmer). Clinical outcomes were collected prospectively before surgery, at 3 months, 1 year, 2 years, 3 years, and at 5 years post surgery. Revision for any cause was taken as the primary endpoint and the roentgenograms and explanted prostheses were analyzed for failure patterns. In the LDH/Durom¯ group a total of 13 (18%) patients required revision (figs. 1) at a median of 35 months (range 6-44). 6 (8%) for periprosthetic fracture. All 6 periprostethic fractures were associated with minimal or no trauma and all had ALVAL identified histologically. To date there have been no failures in the CPT¯/28mm head Allofit¯ group. Several failures demonstrated bone loss in Gruen zones 8 ± 9 ± 10 (fig. 2). We demonstrate an unacceptably high rate of failure in CPT¯ MoM LDH hip replacements, with a high failure secondary to periprosthetic fracture and postulate a mechanism associated with local toxicity to metal ions. We strongly advise against this combination of prosthesis

Periprosthetic fractures are an increasingly common complication following joint replacement. The principles which underpin their evaluation and treatment are common across the musculoskeletal system. The Unified Classification System proposes a rational approach to treatment, regardless of the bone that is broken or the joint involved. Cite this article: Bone Joint J 2014;96-B:713–16

Aims

Revision total hip arthroplasty in patients with Vancouver type B3 fractures with Paprosky type IIIA, IIIB, and IV femoral defects are difficult to treat. One option for Paprovsky type IIIB and IV defects involves modular cementless, tapered, revision femoral components in conjunction with distal interlocking screws. The aim of this study was to analyze the rate of reoperations and complications and union of the fracture, subsidence of the stem, mortality, and the clinical outcomes in these patients.

Aims. Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees. Methods. A retrospective review identified 518 osseointegration procedures which were undertaken in 458 patients between 2010 and 2018 for whom complete medical records were available. Potential risk factors including time since amputation, age at osseointegration, bone density, weight, uni/bilateral implantation and sex were evaluated with multiple logistic regression. The mechanism of injury, technique and implant that was used for fixation of the fracture, pre-osseointegration and post fracture mobility (assessed using the K-level) and the time that the prosthesis was worn for in hours/day were also assessed. Results. There were 22 periprosthetic fractures; they occurred exclusively in the femur: two in the femoral neck, 14 intertrochanteric and six subtrochanteric, representing 4.2% of 518 osseointegration operations and 6.3% of 347 femoral implants. The vast majority (19/22, 86.4%) occurred within 2 cm of the proximal tip of the implant and after a fall. No fractures occurred spontaneously. Fixation most commonly involved dynamic hip screws (10) and reconstruction plates (9). No osseointegration implants required removal, the K-level was not reduced after fixation of the fracture in any patient, and all retained a K-level of ≥ 2. All fractures united, 21 out of 22 patients (95.5%) wear their osseointegration-mounted prosthetic limb longer daily than when using a socket, with 18 out of 22 (81.8%) reporting using it for ≥ 16 hours daily. Regression analysis identified a 3.89-fold increased risk of fracture for females (p = 0.007) and a 1.02-fold increased risk of fracture per kg above a mean of 80.4 kg (p = 0.046). No increased risk was identified for bilateral implants (p = 0.083), time from amputation to osseointegration (p = 0.974), age at osseointegration (p = 0.331), or bone density (g/cm2, p = 0.560; T-score, p = 0.247; Z-score, p = 0.312). Conclusion. The risks and sequelae of periprosthetic fracture after press-fit osseointegration for amputation should not deter patients or clinicians from considering this procedure. Females and heavier patients are likely to have an increased risk of fracture. Age, years since amputation, and bone density do not appear influential. Cite this article: Bone Joint J 2020;102-B(2):162–169

Aims

The aims of this study were to evaluate the incidence of reoperation (all cause and specifically for periprosthetic femoral fracture (PFF)) and mortality, and associated risk factors, following a hemiarthroplasty incorporating a cemented collarless polished taper slip stem (PTS) for management of an intracapsular hip fracture.