High risk of early periprosthetic fractures after primary hip arthroplasty in elderly patients using a cemented, tapered, polished stem

Figures & data

Table 1. Characteristics of subjects. Hips and not individual patients are presented

	No periprosthetic fracture (n = 1,356)	Periprosthetic fracture (n = 47)
Sex ^a
Male	375 (28%)	12 (26%)
Female	981 (72%)	35 (74%)
Age, years ^b	82 (8)	82 (6)
Height, cm ^b	167 (9)	167 (9)
Weight, kg ^b	67 (14)	69 (13)
ASA category ^a
1–2	481 (36%)	17 (36%)
3–4	875 (64%)	30 (64%)
Cognitive dysfunction ^a
No	798 (56%)	32 (68%)
Yes	558 (41%)	15 (32%)
Indication for surgery ^a
Osteoarthritis	359 (27%)	8 (17%)
Femoral neck fracture	997 (73%)	39 (83%)
Acute fracture	889	36
Sequelae	108	3
Type of arthroplasty ^a
THA	616 (45%)	20 (43%)
HA	740 (55%)	27 (57%)
Surgical approach ^a
Posterolateral	536 (40%)	15 (32%)
Direct lateral	820 (60%)	32 (68%)

^a n (%).

^b mean (SD).

Table 2. Cox proportional hazard model to evaluate covariates associated with periprosthetic fracture. In this analysis, only the first-operated hip in the study was analyzed and the sample size is therefore 1,357

Covariate	n	Periprosthetic fracture rate (%)	HR (95% CI)	p-value
Sex
Male	379	3.2	1
Female	978	3.2	0.9 (0.4–1.6)	0.8
Age
< 80 years	444	2.3	1
≥ 80 years	913	3.6	2.0 (1.1-4.5)	0.04
ASA category
1–2	483	3.2	1
3–4	874	3.3	1.2 (0.6–2.3)	0.6
Cognitive dysfunction
No	810	3.8	1
Yes	547	2.6	0.8 (0.5–1.5)	0.6
Indication for surgery
OA	348	1.4	1
Femoral neck fracture	1,009	3.8	4.1 (1.3–12.3)	0.01
Type of arthroplasty
THA	612	2.8	1
HA	745	3.5	0.8 (0.4–1.6)	0.6
Surgical approach
Posterolateral	529	2.7	1
Direct lateral	828	3.8	1.3 (0.7–2.7)	0.4

Table 3. Numbers of hip-related complications leading to reoperation, for the whole cohort and by diagnosis group (for dislocations including closed reduction under general anesthesia). For femoral neck fracture hips, they are also presented separately for THA and HA

			Femoral neck fracture
Hip-related complication	Whole cohort (n = 1,403)	Osteoarthritis (n = 367)	All (n = 1,036)	THA (n = 269)	HA (n = 767)
Periprosthetic fracture	47 (3.3%)	8 (2.2%)	39 (3.8%)	12 (4.5%)	27 (3.5%)
Dislocation	40 (2.9%)	9 (2.5%)	31 (3.0%)	10 (3.7%)	21 (2.7%)
Periprosthetic joint infection	22 (1.6%)	4 (1.1%)	18 (1.7%)	5 (1.9%)	12 (1.7%)
Aseptic loosening (cup)	3 (0.2%)	1 (0.3%)	2 (0.2%)	2 (0.7%)	0 (0.0%)
Other hip- related complication	2 (0.1%)	0 0.0%)	2 (0.2%)	0 (0.0%)	2 (0.3%)

THR: total hip arthroplasty: HA: hemiarthroplasty.

Table 4. Periprosthetic fractures, surgical treatment, and surgical outcome

Vancouver classification
Vancouver A	1
Vancouver B1	4
Vancouver B2	29
Vancouver B3	1
Vancouver C	12
Surgical treatment
Open reduction and
internal fixation (ORIF)	16^a
Stem revision	31^b
Surgical outcome^c
Good	33
Intermediate	9
Poor	2^d
Deceased	3

^aAll type-C fractures, the type-A fracture, and 3 type-B1 fractures were treated with ORIF. In all cases, a femoral locking plate was used.

^b1 type-B1 and all type-B2 and -B3 fractures were treated with stem revision. In all stem revisions, the newly implanted femoral stem was reinforced by a femoral locking plate and/or cerclage wires.

^cThe surgical outcome was no different between type-B2 and type-C fractures.

^d1 type-C fracture went to non-union and the patient is confined to a wheelchair and cannot be reoperated because of severe comorbidities. 1 type-B1 fracture was initially treated with ORIF. The stem was later revised, and the patient developed periprosthetic joint infection and was treated with excision arthroplasty to heal the infection.

Table 5. Accumulated incidence and annual incidence rate in studies on periprosthetic femoral fractures

Study	Selection of patients	No. of hips	No. of PPFs	Years of follow-up	Accumulated incidence (%)	Annual incidence rate (%)
Löwenhielm et al. (1989)	Primary cemented THR	1,442	14	15	2.5%	0–1.2%
Lindahl et al. (2005)	Primary cemented THR	127,744	1,049	22	0.4%	0.045–0.13%
Lewallen and Berry (1998)	Primary arthroplasty	17,579	No data	21	0.6%	No data
Cook et al. (2008)	Primary cemented THR	6,458	124	10	3.5%	No data
Singh et al. (2013)	Primary cemented THR	5,269	115	< 6	2.1%	No data
Brodén et al. (2014)	Primary cemented THR and HA	1,404	47	4	3.3%	1.1%

PPF: periprosthetic fracture; THR: total hip arthroplasty: HA: hemiarthroplasty.

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