PURPOSE: Femur fractures are among the most common fractures treated surgically, representing a significant challenge for the orthopedic surgeon. Peri-implant femoral fractures (PIFFs) represent a rare complication of the surgical treatment. It is necessary to pay attention during osteosynthesis, evaluating not only the fracture site but the entire femoral skeletal structure, the characteristics of the fracture, the health comorbidities, and the risk of malunion and pseudarthrosis. There are few studies on the incidence, treatment, and outcomes of PIFFs near osteosynthesis. This study aimed to investigate PIFF after osteosynthesis of femoral fractures and evaluate the mortality after surgery and the morbidity associated with these types of fractures. METHODS: A retrospective cohort study was carried out at the IRCCS Galeazzi Orthopedic Institute, Milan, Italy, between January, 2017 and December, 2022. Inclusion criteria were the presence of a femur fracture around an intramedullary nail to treat a previous fracture, follow-up ≥ 12 months, and patients aged ≥ 65 years. Exclusion criterion was intraoperative periprosthetic fractures. The data were expressed as frequency and percentage. Continuous variables were expressed as mean ± standard deviation or median and range. RESULTS: Overall, 25 patients were enrolled (88.0% female) and the mean age was 84.5 years (range of 70 - 92 years). There were 20 patients having type B PIFF and 5 having type C. In 22 patients, multiple comorbidities were found with an average Charlson comorbidity score of 5.5 and the mean time to peri-implant fracture was 38 months. After surgery, 1 patient (4.0%) presented renal failure, 1 (4.0%) needed removal surgery for their loosening, and 2 (8.0%) presented surgical site infection. Nine patients (36.0%) died within 1 year with a mortality rate of 20.0% at 30 days, 8.0% at 3 months, and 8.0% at 12 months. CONCLUSIONS PIFFs in elderly patients are associated with high short-term mortality and morbidity, so careful planning for primary fracture surgery and patient awareness to ensure prolonged compliance and a healthy lifestyle are essential for prevention.
Humans ; Female ; Male ; Aged ; Femoral Fractures/mortality* ; Retrospective Studies ; Aged, 80 and over ; Periprosthetic Fractures/epidemiology* ; Fracture Fixation, Intramedullary/adverse effects* ; Postoperative Complications/mortality*

OBJECTIVE: To construct and evaluate nomogram prediction model for periprosthetic fractures in patients undergoing total hip arthroplasty (THA). METHODS: A total of 538 patients who underwent THA from April 2013 to February 2019 were selected as the research subjects, including 318 males and 220 females, aged 40 to 60 years old with an average age of (50.79±6.37) years old. All patients with THA were divided into non-fracture group (506 patients) and fracture group (32 pathents) according to the 3-year follow-up results. Univariate and multivariate Logistic regression analyses were performed to analyze the influencing factors of postoperative periprosthetic fractures in patients with THA. A nomogram prediction model for periprosthetic fractures in patients undergoing THA was constructed, and the validity and discrimination of the prediction model were evaluated. RESULTS: The proportion of patients with osteoporosis, trauma history, and hip revision in the fracture group were higher than those in the non-fracture group(P<0.05), and the proportion of bone cement prosthesis was lower than that in the non-fracture group(P<0.05). The osteoporosis status[OR=4.177, 95%CI(1.815, 9.617), P<0.05], trauma history[OR=7.481, 95%CI(3.104, 18.031), P<0.05], and hip revision[OR=11.371, 95%CI(3.220, 40.153, P<0.05] were independent risk factors for postoperative periprosthetic fractures in patients undergoing THA, cemented prosthesis [OR=0.067, 95%CI(0.019, 0.236), P<0.05] was an independent protective factor for postoperative periprosthetic fractures in patients undergoing THA(P<0.05). Hosmer-Lemeshow goodness of fit test showed that χ²=7.864, P=0.325;the area under the curve (AUC) for periprosthetic fractures in patients undergoing THA was 0.892 with a sensitivity of 87.5% and a specificity of 77.7% by receiver operating characteristic(ROC) curve. CONCLUSION The nomogram prediction model for periprosthetic fractures after THA constructed in this study has good discrimination, which is beneficial to clinical prediction of periprosthetic fractures in patients undergoing THA, and facilitates individualized fracture prevention.
Male ; Female ; Humans ; Adult ; Middle Aged ; Arthroplasty, Replacement, Hip/adverse effects* ; Periprosthetic Fractures/surgery* ; Nomograms ; Reoperation/adverse effects* ; Risk Factors ; Osteoporosis/surgery* ; Retrospective Studies ; Hip Prosthesis

PURPOSE: Non-prosthetic peri-implant fractures are challenging injuries. Multiple factors must be carefully evaluated for an adequate therapeutic strategy, such as the state of bone healing, the type of implant, the time and performed personnel of previous surgery, and the stability of fixation. The aim of this study is to propose a rationale for the treatment. METHODS: The peri-implant femoral fractures (PIFFs) system, a therapeutic algorithm was developed for the management of all patients presenting a subtype A PIFF, based on the type of the original implant (extra- vs. intra-medullary), implant length and fracture location. The adequacy and reliability of the proposed algorithm and the fracture healing process were assessed at the last clinical follow-up using the Parker mobility score and radiological assessment, respectively. In addition, all complications were noticed. Continuous variables were expressed as mean and standard deviation, or median and range according to their distribution. Categorical variables were expressed as frequency and percentages. RESULTS: This is a retrospective case series of 33 PIFFs, and the mean post-operative Parker mobility score was (5.60 ± 2.54) points. Five patients (15.1%) achieved complete mobility without aids (9 points) and 1 (3.0%) patient was not able to walk. Two other patients (6.1%) were non-ambulatory prior to PPIF. The mean follow-up was (21.51 ± 9.12) months (range 6 - 48 months). There were 7 (21.2%) complications equally distributed between patients managed either with nailing or plating. There were no cases of nonunion or mechanical failure of the original implant. CONCLUSION The proposed treatment algorithm shows adequate, reliable and straightforward to assist the orthopaedic trauma surgeon on the difficult decision-making process regarding the management of PIFF occurring in previously healed fractures. In addition, it may become a useful tool to optimize the use of the classification, thus potentially improving the outcomes and minimizing complications.
Humans ; Periprosthetic Fractures/surgery* ; Retrospective Studies ; Femoral Fractures/surgery* ; Reproducibility of Results ; Fracture Fixation, Internal ; Fracture Healing ; Treatment Outcome

OBJECTIVE: To analyze and compare the clinical efficacy of different types of surgical treatment of periprosthetic femoral fracture(PFF) after hip arthroplasty (HA). METHODS: From September 2010 to September 2016, 47 patients (47 hips) with periprosthetic fractures after total hip arthroplasty were retrospectively analyzed, including 13 males and 34 females. According to Vancouver classification, there were 2 patients with type AG, 17 patients with type B1, 19 patients with type B2, 7 patients with type B3 and 2 patients with type C. The age of patients ranged from 56 to 94 (71.5±8.3) years. After admission, nutritional risk screening (NRS2002) was used to assess the nutritionalstatus of the patients. Eighteen patients (38%) had malnutrition risk (NRS>3 points). After admission, the patients were given corresponding surgical treatment according to different types. Intraoperative blood loss was recorded. Harris score was used to evaluate the hip function. VAS pain score was performed on admission and after operation. RESULTS: All the 47 patients were followed up for 19 to 62 (34±11) months. The Harris scores were (41.8±12.1) and (89.0±2.6) respectively before and 1 year after operation, and the difference was statistically significant ( CONCLUSION The treatment of hip periprosthetic fracture patients should be based on the general situation of patients, imaging data, intraoperative correction classification, etc. to develop individualized treatment plan in line with patients. For patients with preoperative malnutrition risk, preoperative nutritional intervention may reduce intraoperative bleeding.
Aged ; Aged, 80 and over ; Arthroplasty, Replacement, Hip/adverse effects* ; Female ; Femoral Fractures/surgery* ; Fracture Fixation, Internal ; Hip Prosthesis ; Humans ; Male ; Middle Aged ; Periprosthetic Fractures/surgery* ; Reoperation ; Retrospective Studies ; Treatment Outcome

OBJECTIVE: To evaluate the clinical effect of bridge combined internal fixation system in the treatment of periprosthesis fracture of femur after hip replacement. METHODS: From October 2016 to June 2018, 5 patients of periprosthesis fractures of femur classified type B1 and type C in Vancouver were treated by open reduction and bridging combined with internal fixation, including 2 males and 3 females, with ages of 68, 70, 74, 75, 79 years;type B1 fractures in 4 and type C fractures in 1. Causes of injury:1 case of traffic injury, 4 cases of fall. After the operation, the patients were followed up for complications and fracture healing time by clinical and imaging examination, and Parker activity score was performed. RESULTS: The wounds of 5 patients healed without infection. One case of DVT was confirmed by venography. Five patients were followed up, and the durations were 2, 8, 9, 10, 15 months. One patient died of myocardial infarction 2 months after operation. The average healing time was 12.5 weeks. No loss of reduction or failure of internal fixation was found. Two patients could walk without protection and 1 patient needed to rely on single crutch. One case of periprosthetic fracture had to walk with a single crutch before operation and move indoors with two crutches after operation. The average Parker activity score was 51.8% before operation. CONCLUSION The bridge combined internal fixation system can be used to fix the fracture after hip replacement with stable femoral prosthesis.
Aged ; Arthroplasty, Replacement, Hip ; Bone Plates ; Female ; Femoral Fractures ; surgery ; Fracture Fixation, Internal ; Fracture Healing ; Humans ; Male ; Periprosthetic Fractures ; surgery ; Radiography ; Reoperation ; Retrospective Studies ; Treatment Outcome

Recently, as the elderly population increases, the incidence of total knee arthroplasty has increased, with a concomitant increase in the frequency of periprosthetic fractures. To determine the treatment plan for fractures, the treatment method should be determined by the patient's age, osteoporosis, fixation status of the implant, and type of fracture. In recent years, operative treatment with reduction and stable fixation, rather than non-operative treatment, was used to promote early joint movement and gait. On the other hand, it is necessary to select an appropriate operative method to reduce complications of surgery, such as nonunion and infection, and expect a good prognosis. In this review, periprosthetic fractures were divided into femur, tibia, and patella fractures, and their causes, risk factors, classification, and treatment are discussed.
Aged ; Arthroplasty ; Arthroplasty, Replacement, Knee ; Classification ; Femur ; Gait ; Hand ; Humans ; Incidence ; Joints ; Knee ; Methods ; Osteoporosis ; Patella ; Periprosthetic Fractures ; Prognosis ; Risk Factors ; Tibia

Although the incidence of postoperative periprosthetic femoral fractures after hip arthroplasty is expected to increase, these complex fractures are still challenging complications. To obtain optimal results for these fractures, thorough clinical and radiographic evaluation, precise classification, and understanding of modern management principles are mandatory. The Vancouver classification system is a simple, effective, and reproducible method for planning proper treatments of these injuries. The fractures associated with a stable femoral stem can be effectively treated with osteosynthesis, though periprosthetic femoral fractures associated with a loose stem require revision arthroplasty. We describe here the principles of proper treatment for the patients with periprosthetic femoral fractures as well as how to avoid complications.
Arthroplasty ; Classification ; Femoral Fractures ; Femur ; Hip ; Humans ; Incidence ; Methods ; Periprosthetic Fractures

A 98-year-old male patient with history of hemiarthroplasty suffered periprosthetic fracture of right femoral shaft and developed acute coronary event in three days after hospitalization. Femoral nerve and lateral femoral cutaneous nerve blocks combined with general anesthesia were implemented for the internal fixation surgery. The recovery was uneventful after discharge. In this case report, we discussed the main considerations of anesthesia specifically for this complicated case.
Aged, 80 and over ; Anesthesia, General ; Femoral Fractures/surgery* ; Humans ; Male ; Periprosthetic Fractures/surgery*

PURPOSE: The difficulty of femoral preparation with supine-position hip hemi-arthroplasty (HA) often leads to intra-operative fractures (IOFs). We aimed to clarify the incidence and types of IOFs in HA for hip fractures performed in the supine and lateral positions. MATERIALS AND METHODS: We retrospectively investigated cases of HA for acute femoral neck fractures from June 2013 to May 2018. We examined the incidence and types of IOFs according to different approaches. We defined supine-position in HA as the supine and hip-hyperextended (over-range) femoral preparation position, and lateral position as the lateral and hip-flexed femoral preparation position. We used a short tapered wedged stem. RESULTS: Supine-position HA was used in 46 patients (23.7%) and lateral-position HA in 148 patients (76.3%). IOFs in supine-position HA occurred in 8 patients (17.4%) and included five Vancouver AGT and three Vancouver B2 fractures. IOFs in lateral-position HA occurred in 3 patients (2.0%) and included one Vancouver AGT and two Vancouver B fractures. Supine-position HA was a risk factor for IOFs (adjusted odds ratio, 9.71; 95% confidence interval, 2.37–39.8; P < 0.01) CONCLUSION: Supine-position in HA is an IOF risk factor and significantly increases the incidence of great trochanter fractures of Vancouver type A.
Arthroplasty, Replacement, Hip ; Femoral Neck Fractures ; Femur ; Hemiarthroplasty ; Hip Fractures ; Hip ; Humans ; Incidence ; Minimally Invasive Surgical Procedures ; Odds Ratio ; Periprosthetic Fractures ; Retrospective Studies ; Risk Factors

PURPOSE: Tumor infiltration around the knee joint or skip metastasis, repeated infection sequelae after tumor prosthesis implantation, regional recurrence, and mechanical failure of the megaprosthesis might require combined distal femur and proximal tibia replacement (CFTR). Among the aforementioned situations, there are few reports on the indication, complications, and implant survival of CFTR in temporarily arthrodesed patients who had a massive bony defect on either side of the knee joint to control infection. MATERIALS AND METHODS: Thirty-four CFTR patients were reviewed retrospectively and 13 temporary arthrodesed cases switched to CFTR were extracted. All 13 cases had undergone a massive bony resection on either side of the knee joint and temporary arthrodesis state to control the repeated infection. This paper describes the diagnosis, tumor location, number of operations until CFTR, duration from the index operation to CFTR, survival of CFTR, complications, and Musculoskeletal Tumor Society (MSTS) score. RESULTS: According to Kaplan-Meier plot, the 5- and 10-year survival of CFTR was 69.0%±12.8%, 46.0%±20.7%, respectively. Six (46.2%) of the 13 cases had major complications. Three cases underwent removal of the prosthesis and were converted to arthrodesis due to infection. Two cases underwent partial change of the implant due to loosening and periprosthetic fracture. The remaining case with a deep infection was resolved after extensive debridement. At the final follow-up, the average MSTS score of 10 cases with CFTR was 24.6 (21–27). In contrast, the MSTS score of 3 arthrodesis cases with failed CFTR was 12.3 (12–13). The average range of motion of the 10 CFTR cases was 67° (0°–100°). The mean extension lag of 10 cases was 48° (20°–80°). CONCLUSION: Although the complication rates is substantial, conversion of an arthrodesed knee to a mobile joint using CFTR in a patient who had a massive bony defect on either side of the knee joint to control infection should be considered. The patient's functional outcome was different from the arthrodesed one. For successful conversion to a mobile joint, thorough the eradication of scar tissue and creating sufficient space for the tumor prosthesis to flex the knee joint up to 60° to 70° without soft tissue tension.
Arthrodesis ; Cicatrix ; Debridement ; Diagnosis ; Extremities ; Femur ; Follow-Up Studies ; Humans ; Joints ; Knee Joint ; Knee ; Limb Salvage ; Neoplasm Metastasis ; Osteosarcoma ; Periprosthetic Fractures ; Prostheses and Implants ; Prosthesis Implantation ; Range of Motion, Articular ; Recurrence ; Retrospective Studies ; Tibia