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Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_1 | Pages 7 - 7
1 Jan 2022
Nebhani N Ogbuagu C Kumar G
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Abstract

Background

Atypical femur fracture (AFF) is a well known complication of Bisphosphonate therapy. Due to prolonged suppression of bone re-modelling in these fractures, surgical complications are difficult to manage. The aim of this study was to analyze the causes of surgical complications in AFF fixations and provide algorithm for management.

Method

In this retrospective 10-year study (2010–2020), we identified patients surgically treated for AFF. We included patients who underwent revision surgery for any cause. Data collection included demographics, surgical complications, details of revision surgery and time to union.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_14 | Pages 11 - 11
23 Jul 2024
Sarhan M Moreau J Francis S Page P
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Hip fractures frequently occur in elderly patients with osteoporosis and are rapidly increasing in prevalence owing to an increase in the elderly population and social activities. We experienced several recent presentations of TFNA nails failed through proximal locking aperture which requires significant revision surgery in often highly co-morbid patient population.

The study was done by retrospective data collection from 2013 to 2023 of all the hip fractures which had been fixed with Cephalomedullary nails to review and compare Gamma (2013–2017) and TFNA (2017–2023) failure rates and the timing of the failures. Infected and Elective revision to Arthroplasty cases were excluded.

The results are 1034 cases had been included, 784 fixed with TFNA and 250 cases fixed Gamma nails. Out of the 784 patients fixed with TFNA, 19 fixation failed (2.45%). Out of the 250 cases fixed with Gamma nails, 15 fixation failed (6%). Mean days for fixation failure were 323 and 244 days in TFNA and Gamma nails respectively.

We conclude that TFNA showed remarkable less failure rates if compared to Gamma nails. At point of launch, testing was limited and no proof of superiority of TFNA over Gamma nail. Several failures identified with proximal locking aperture in TFNA which can be related to the new design which had Substantial reduction in lateral thickness at compression screw aperture.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVIII | Pages 137 - 137
1 Sep 2012
Duffy PJ Gray A Powell J Mitchell J Tyberg J
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Purpose. There are concerns with regard to the physiological effects of reamed intramedullary femoral fracture stabilisation in patients who have received a pulmonary injury. This large animal study used invasive monitoring techniques to obtain sensitive cardiopulmonary measurements and compared the responses to Early Total Care (reamed intramedullary femoral fracture fixation) to Damage Control Orthopaedics (external fixation), after the induction of acute lung injury. We hypothesised a greater cardiopulmonary response to intramedullary fracture fixation. Method. Acute lung injury (PaO2/FiO2 < 200 mmHg) was induced in 12 invasively monitored and terminally anaesthetised male sheep via the infusion of oleic acid into the right atrium. Each animal underwent surgical femoral osteotomy and fixation with either reamed intramedullary (n=6) or external fixation (n=6). Simultaneous haemodynamic and arterial blood-gas measurements were recorded at baseline and at 5, 30 and 60 minutes after fracture stabilisation. Results. The mean (S.E.) PaO2/FiO2 fell significantly (p<0.05) from 359(37) to 107 (23) and 382 (33) to 128 (18) in the externally fixated and intramedullary nailed groups respectively as a result of the acute lung injury. The further combined effect of surgical osteotomy and subsequent fracture fixation produced a mean (+/− S.E.) PaO2/FiO2 of 114 (21) and 113 (12), in the externally fixated and intramedullary nailed groups respectively, immediately after surgery. This was not significantly different either within or between groups. Similarly the pulmonary vascular resistance (PVR) measured at 4.7 (0.9) and 4.2 (0.5) in the externally fixated and intramedullary nailed groups respectively after lung injury changed to 4.9 (0.7) and 4.3 (0.6) after surgical osteotomy and subsequent fracture fixation which, again was not significantly different either within or between groups. No significant difference in either PaO2/FiO2 or PVR was detected at the monitored 5, 30 and 60 minute intervals that followed fracture stabilisation. Conclusion. Against a background of standardised acute lung injury, there appeared to be no further deterioration produced by the method of isolated femoral fracture fixation in two sensitive physiological parameters commonly used by intensive care physicians


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_21 | Pages 90 - 90
1 Dec 2016
Schemitsch E Walmsley D McKee M Nauth A Waddell J
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Proximal femur fractures are increasing in prevalence, with femoral neck (FN) and intertrochanteric (IT) fractures representing the majority of these injuries. The salvage procedure for failed open reduction internal fixation (ORIF) is often a conversion to total hip arthroplasty (THA). The use of THA for failed ORIF improves pain and function, however the procedure is more challenging. The aim of this study was to investigate the clinical and radiographic outcomes in patients who have undergone THA after ORIF.

This retrospective case-control study compared patients who underwent THA after failed ORIF to a matched cohort undergoing primary THA for non-traumatic osteoarthritis. From 2004 to 2014, 40 patients were identified. The matched cohort was matched for date of operation, age, gender, and type of implant. Preoperative, intraoperative, and postoperative data were collected and statistical analysis was performed.

The cohort of patients with a salvage THA included 18 male and 22 female patients with a mean age of 73 years and mean follow up of 3.1 years. Those with failed fixation included 12 IT fractures and 28 FN fractures. The mean time between ORIF and THA was 2.1 years for IT fractures and 8.5 years for FN fractures (p=0.03). The failed fixation group had longer procedures, greater drop in hemoglobin, and greater blood transfusion rate (p<0.05). There was one revision and one dislocation in the failed fixation group with no revisions or dislocations in the primary THA group. Length of admission, medical complications, and functional outcome as assessed with a standardised hip score and were found not to be statistically different between the groups.

Salvage THA for failed initial fixation of proximal femur fractures yields comparable clinical results to primary THA with an increased operative time, blood loss, and blood transfusion rate.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_22 | Pages 17 - 17
1 May 2013
Haidukewych G
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Although the vast majority of fractures of the proximal femur will heal with well-done internal fixation, occasionally failure of fixation will occur. Having effective salvage options is important to restore function and minimize complications. In general, it is logical to separate salvage options into those for fractures of the femoral neck, and those for fractures of the intertrochanteric region. Additionally, patient age and remaining bone stock should be considered.

Femoral neck fracture fixation failure salvage, young patients: All efforts are focused on preserving the native femoral neck. Valgus producing osteotomy is typically indicated, and can be successful even with small patches of AVN.

Femoral neck fracture fixation failure salvage, older patients: Total hip arthroplasty is generally most predictable. Be prepared for very poor bone quality. Supplement uncemented acetabular component with multiple screws. Be prepared to cement femoral component if necessary.

Intertrochanteric fracture fixation failure salvage, young patients: Repeat internal fixation attempts with fixed angle devices (such as a 95 degree blade plate) and bone grafting generally preferred. Avoid varus of proximal fragment and target inferior femoral head bone.

Intertrochanteric fracture fixation failure salvage, older patients: Total hip arthroplasty preferred. Long stems to bypass femoral shaft stress risers and “calcar replacement” stems may be necessary due to proximal bone defects. Trochanteric fixation must be stable. Results are generally good but trochanteric complaints are common.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_19 | Pages 2 - 2
1 Apr 2013
Thukral R Marya S
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Introduction

Failed operated intertrochanteric fractures (with screw cutout, joint penetration, varus collapse, nonunion, or femoral head avascular necrosis) pose treatment dilemmas. The ideal approach is re-osteosynthesis with autologous bone grafting. When the femoral head is unsalvageable, conversion to a prosthetic hip replacement is necessary.

Materials/Methods

Thirty-seven patients with failed dynamic hip screw fixation (and unsalvageable femoral heads) were treated with cementless hip arthroplasty (13 underwent Bipolar Arthroplasty, 24 had Total Hip Arthroplasty) over a 5-year period (Dec 2005 to Nov 2010). Seven needed a modified trochanteric split, and the rest were managed by standard anterolateral approach. Abductor mechanism was reconstructed using strong nonabsorbable sutures (ethibond 5) or stainless steel wires. The calcar was partially reconstructed using remnant femoral head and cerclage wiring in a few cases.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_2 | Pages 69 - 69
10 Feb 2023
Tong Y Holmes S Sefton1 A
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There is conjecture on the optimal timing to administer bisphosphonate therapy following operative fixation of low- trauma hip fractures. Factors include recommendations for early opportunistic commencement of osteoporosis treatment, and clinician concern regarding the effect of bisphosphonates on fracture healing. We performed a systematic review and meta-analysis to determine if early administration of bisphosphonate therapy within the first month post-operatively following proximal femur fracture fixation is associated with delay in fracture healing or rates of delayed or non-union. We included randomised controlled trials examining fracture healing and union rates in adults with proximal femoral fractures undergoing osteosynthesis fixation methods and administered bisphosphonates within one month of operation with a control group. Data was pooled in meta-analyses where possible. The Cochrane Risk of Bias Tool and the GRADE approach were used to assess validity. For the outcome of time to fracture union, meta-analysis of three studies (n= 233) found evidence for earlier average time to union for patients receiving early bisphosphonate intervention (MD = −1.06 weeks, 95% CI −2.01 – −0.12, I. 2. = 8%). There was no evidence from two included studies comprising 718 patients of any difference in rates of delayed union (RR 0.61, 95% CI 0.25–1.46). Meta-analyses did not demonstrate a difference in outcomes of mortality, function, or pain. We provide low-level evidence that there is no reduction in time to healing or delay in bony union for patients receiving bisphosphonates within one month of proximal femur fixation


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_15 | Pages 97 - 97
1 Aug 2017
Lachiewicz P
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Using the Mayo Clinic definition (>62mm in women and >66mm in men), the “jumbo acetabular component” is the most successful method for acetabular revisions now, even in hips with severe bone loss. There are numerous advantages: surface contact is maximised; weight-bearing is distributed over a large area of the pelvis; the need for bone grafting is reduced; and usually, hip center of rotation is restored. The possible disadvantages of jumbo cups include: may not restore bone stock; may ream away posterior column or wall; screw fixation required; the possibility of limited bone ingrowth and late failure; and a high rate of dislocation due to acetabular size:femoral head ratio. The techniques for a successful jumbo revision acetabular component involve: sizing-“reaming” of the acetabulum, careful impaction to achieve a “press-fit”, and multiple screw fixation. We recommend placement of an ischial screw in addition to dome and posterior column screw fixation. Cancellous allograft is used for any cavitary defects. The contra-indications for a jumbo acetabular cup are: pelvic dissociation; inability to get a rim fit; and inability to get screw fixation. If stability cannot be achieved with the jumbo cup alone, then use of augment(s), bulk allograft, or cup-cage construct should be considered. Using titanium fiber-metal mesh components, we reported the 15-year survival of 129 revisions. There was 3% revision for deep infection and only 3% revision for aseptic loosening. There were 13 reoperations for other reasons: wear, lysis, dislocation, femoral loosening, and femoral fracture fixation. The survival was 97.3% at 10 years, but it dropped to 82.8% at 15 years. Late loosening of this fiber metal mesh component is likely related to polyethylene wear and loss of fixation. Dislocation is the most common complication of jumbo acetabular revisions, approximately 10%, and these are multifactorial in etiology and often require revision. Based on our experience, we now recommend use of an acetabular component with an enhanced porous coating (tantalum), highly crosslinked polyethylene, and large femoral heads or dual mobility for all jumbo revisions


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_1 | Pages 62 - 62
1 Feb 2015
Lachiewicz P
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Using the Mayo Clinic definition (>62mm in women and >66mm in men), the “jumbo acetabular component” is the most commonly used method for acetabular revisions now. There are numerous advantages: surface contact is maximised; weight-bearing is distributed over a large area of the pelvis; the need for bone grafting is reduced; and usually, hip center of rotation is restored. The possible disadvantages, or caveats, of jumbo cups include: may not restore bone stock; may ream away posterior column or wall; screw fixation required; the possibility of limited bone ingrowth and late failure; and a high rate of dislocation due to acetabular size:femoral head ratio. The techniques for a successful jumbo revision acetabular component involve: sizing-“reaming” of the acetabulum, careful impaction to achieve a “press-fit”, and multiple screw fixation. We recommend placement of an ischial screw in addition to dome and posterior column screw fixation. Cancellous allograft is used for any cavitary defects. The contraindications for a jumbo acetabular cup are: pelvic dissociation; inability to get a rim fit; inability to get screw fixation; and the presence of <50% living host bone. If stability cannot be achieved with the jumbo cup alone, then use of augment(s), bulk allograft, or cup-cage construct should be considered. Our results with the jumbo acetabular cups in revision arthroplasty have been reported. Using predominantly titanium fiber-metal mesh components, we reported the 15-year survival of 129 revisions. There was 3% revision for deep infection and only 3% revision for aseptic loosening. There were 13 reoperations for other reasons: wear, lysis, dislocation, femoral loosening, and femoral fracture fixation. The survival was 97.3% at 10 years, but it dropped to 82.8% at 15 years. Late loosening of this fiber metal mesh component is likely related to polyethylene wear and loss of fixation. Dislocation is the most common complication of jumbo acetabular revisions, approximately 10%, and these are multifactorial in etiology and often require revision. Based on our experience, we now recommend use of an acetabular component with an enhanced porous coating (tantalum), highly cross-linked polyethylene, and large femoral heads for all jumbo revisions


Orthopaedic Proceedings
Vol. 102-B, Issue SUPP_2 | Pages 15 - 15
1 Feb 2020
Coden G Moore T Hushmendy S Hepinstall M
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Introduction. Cementless acetabular fixation in total hip replacement (THA) is reliable and has been the fixation method of choice in the United States for decades. While revision for failure of osseointegration or early loosening is relatively rare, recurrent dislocation remains a leading cause of early revision. Novel acetabular implants and those offered by smaller companies often lack constrained or dual mobility liners, which may result in revision of well-fixed, well-positioned cups in cases of recurrent dislocation. The purpose of this study was to compare outcomes of THA with three different acetabular cups with differing fixation surfaces. One hydroxyapatite (HA)-coated cup (Trident, Stryker, Kalamazoo, MI, USA) offered dual mobility or constrained liner options. The other cups were a novel highly porous cup (Restoris PST, Stryker, Kalamazoo, MI, USA), and a Calcium Phosphate (CaP)-coated cup (Trinity, Corin, Cirincester, UK), neither of which offered dual mobility or constrained options at the time of investigation. Endpoints of interest were: clinical and radiographic outcomes including evidence of osseointegration, overall reoperations, reoperations for acetabular fixation failure, and reoperations to address dislocation in which a well-positioned shell was revised due to the lack of dual mobility or constrained options. Methods. A retrospective review of 370 acetabular cups implanted in 328 patients for THA by a single surgeon between February 2013 and June 2016 was performed. There were 100 Trident cups (Stryker, Kalamazoo, MI, USA), 105 Restoris PST Acetabular Cups (Stryker, Kalamazoo, MI, USA), and 165 Trinity Acetabular Cups (Corin, Cirincester, UK). Patient records were reviewed for post-operative complications, clinical outcomes scores and radiographic signs of acetabular osseointegration at minimum 1-year follow-up. Results. Despite differences in fixation surface, there was no difference in Harris Hip Scores at minimum 1-year follow-up and all three cohorts had 100% 1-year survivorship free of revision for failure of acetabular fixation. No cup showed signs of acetabular migration or loosening. Overall reoperation rates were low, ranging from 2.4%-3.8% (p=0.81). Femoral fractures and fixation problems were the most common cause of reoperation, occurring in nearly 2% of cases (n=7), but did not differ between groups. Reoperation for infection occurred in less than 1% of cases (n=3) and did not differ between groups. Revision for recurrent dislocation occurred in 1% of cases (n=4). All occurred with cups lacking dual mobility or constrained options. In all 4 cases the acetabular component was within the Lewinnek “safe zone” and deemed well positioned. In one revision, a lipped liner and longer head were used given concerns about the risk of acetabular component revision due to poor bone stock. In the remaining revisions, the well-positioned cup was revised to allow for the use of constrained or dual mobility implants. Conclusion. All acetabular revisions in our cohort were related to instability or infection, while none were related to acetabular fixation. Subsequent to this experience and analysis, we are wary to select any “new and improved” acetabular cup that does not have an option for a constrained or dual mobility liner, even when enabling technology makes us confident of safe-zone placement. For any figures or tables, please contact authors directly


Introduction. To compare the union rates and post-operative mobility of antegrade intramedullary nailing of osteoporotic traumatic supracondylar femoral fractures (AO classification A to C2) with those of plating. Materials/Methods. We studied any traumatic intra or extra-articular supracondylar femoral fracture from 2005–2010. Patients were either admitted directly to our level 1 trauma centre or were referred from another hospital. Nineteen patients were identified, consisting of primarily fixation with five antegrade nails and fourteen plates. We defined osteoporotic bone as being present in anyone over sixty years old or who had a clinical diagnosis. One nail and six plates were excluded due to young age or fracture severity. This left four nails, six less invasive stabilisation system plates and two dynamic condylar screw plates. Both groups were comparable with respect to age, sex and AO fracture classification. Results. There was a significant difference in achieving union between the two groups (p=0.040). Union occurred within three months in all four fractures in the nail group but only three fractures (38%) united after primary fixation in the plate group. There were two failures due to screw pullout, one failure due to screw breakage, one broken plate after delayed-union and one screw breakage after non-union. The patients in the nail group had better mobility and less pain than the plate group but the difference was not statistically significant. Conclusion. We have shown that for patients with osteoporotic, supracondylar femoral fractures, fixation with an antegrade IM nail provides significantly better healing compared to plate fixation


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_II | Pages 72 - 72
1 Feb 2012
Gray A White T Clutton R Hawes B Christie J Robinson C
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Damage Control techniques involve primary external fracture fixation to reduce the ‘second hit’ of surgery. This study used a large animal (ovine) trauma model to compare pathophysiological responses of primary external femoral fixation and intramedullary stabilisation. Under terminal anaesthesia bilateral femoral fractures and hypovolaemia were produced using a pneumatic ram. 24 sheep were randomised into 4 groups and monitored for 24 hours. Group 1 – Control; Group 2 – Trauma only; Group 3 – Trauma and external fixation; Group 4 – Trauma and reamed intramedullary stabilisation. Outcome measures: pulmonary embolic load (transoesophageal echocardiography); plasma coagulation markers; bronchoalveolar lavage differential cell counts (neutrophils, lymphocytes and macrophages). Total embolic load was significantly higher (p<0.001) in the intramedullary fixation group (median score 42 versus 20). All trauma groups had a significant increase (p < 0.05) in prothrombin time with a fall in antithrombin III and fibrinogen levels. No significant differences occurred between trauma groups with any coagulation or alveolar lavage marker. Intramedullary femoral fracture fixation produced a relatively higher pulmonary embolic load. However, the initial fracture fixation method did not affect any of the changes seen in the measured coagulation or inflammatory markers during the first 24 hours of injury


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVIII | Pages 37 - 37
1 Sep 2012
Nicholls F Filomeno PA Willett TL Grynpas MD Ferguson P
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Purpose. The focus of current management of soft tissue sarcoma on limb preservation often necessitates that patients undergo multimodal treatment, including both surgery and external beam radiotherapy. Pathologic fracture is a serious, late complication of radiotherapy. In patients who have also undergone wide excision of soft tissue sarcoma, nonunion rates of 80–90% persist despite optimal internal fixationMany sequelae of the treatments for soft tissue sarcoma exhibit the potential to perpetuate failure of bony union. Limb salvage surgery is associated with extensive periosteal excision, disruption of vascular supply and eradication of local osteoprogenitor cells. External beam radiotherapy leads to obliterative endarteritis, decreased osteoblast proliferation and reduction in bone matrix production. We hypothesize that the combination of radiotherapy and surgical periosteal stripping leads to greater impairment in the fracture repair process than either intervention alone will produce. Method. We developed a method for creating a reproducible, low energy, simple femoral fracture in an animal model designed to proceed to nonunion. Female Wistar, retired breeder rats were separated into four treatment groups of 18 animals each: control, radiotherapy, surgery and combination radiotherapy and surgery. Animals were then further randomized to temporal end-points of 21, 28 and 35 days post-fracture. Designated animals first underwent external beam radiotherapy, followed by surgical stripping of the periosteum three weeks later and femoral fracture with fixation after another three weeks. Animals were sacrificed at their randomly assigned end-points. Results. The fracture device was shown to produce simple, transverse or short oblique femoral fractures using x-rays obtained immediately following fracture, validating the reliability of the model. No significant differences were observed in the force required for fracture between treatment groups. Mineralized callus was observed in control animals and those undergoing periosteal stripping alone, but was absent in all animals receiving radiotherapy. Reactive bone formation was observed in animals undergoing periosteal stripping alone, but was absent when preceded by radiotherapyMicroCT analysis confirmed the results visualized on plain x-ray. No callus formation was observed in animals undergoing radiotherapy and significantly less mineralized callus was produced in animals undergoing periosteal stripping when compared to control. Preliminary studies have shown an absence of cellular activity in animals undergoing radiotherapy, suggesting that fracture in these animals will proceed to nonunion. Conclusion. Early results suggest that this pre-clinical model of combined radiation and surgical periosteal stripping prior to controlled fracture reliably results in nonunion. We expect to utilize this model to examine interventions designed to improve fracture healing in this difficult clinical situation