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Individualized Stem-positioning in Calcar-guided Short-stem Total Hip Arthroplasty
Published on: February 27, 2018
Three Differing Methods of Treating Intraoperative Nondisplaced Calcar Fractures Demonstrate Similar Radiographic
Enrico M Forlenza1, John D D Higgins1, Timothy C Keating1
1Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois.
Insights
Managing intraoperative calcar fractures during total hip arthroplasty (THA) with cerclage cables (CCs), modular tapered-fluted stems (MTF), or fully-coated stems (FC) showed minimal subsidence. However, reoperation risks were higher than anticipated across all THA fracture management strategies.
Area of Science:
- Orthopedic Surgery
- Biomedical Engineering
Background:
- Intraoperative calcar fractures during total hip arthroplasty (THA) require effective management strategies.
- Current approaches include cerclage cables (CCs), modular tapered-fluted (MTF) stems, or fully-coated (FC) diaphyseal-engaging stems.
Purpose of the Study:
- To compare the radiographic and clinical outcomes of three distinct intraoperative calcar fracture management strategies in THA.
- To evaluate stem subsidence and complication rates for each treatment approach.
Main Methods:
- Retrospective review of 50 patients with intraoperative calcar fractures from 9,129 primary THAs.
- Patients were managed with CCs, MTF stems, or FC stems by three different surgeons.
- Stem subsidence was assessed radiographically at 3 months and 1 year; complication rates were evaluated.
Main Results:
- No significant difference in stem subsidence was observed at 3 months or 1 year across the CC, MTF, and FC groups.
- Overall reoperation rate was 12%, with infections in the FC group and fractures in MTF/FC groups.
- Instability requiring closed reduction occurred in the CC group.
Conclusions:
- All three management strategies for intraoperative calcar fractures resulted in low radiographic stem subsidence.
- The overall risk of reoperation associated with these THA fracture management techniques was higher than expected.
Background:
Several management strategies have been described to treat intraoperative calcar fractures during total hip arthroplasty (THA), including retaining the primary implant and utilizing cerclage cables (CCs) or switching the implant to one that bypasses the fracture and achieves diaphyseal fixation. However, the radiographic and clinical outcomes of these differing strategies have never been described and compared.
Methods:
We retrospectively identified 50 patients who sustained an intraoperative calcar fracture out of 9,129 primary total hip arthroplasties (0.55%) performed by one of three surgeons between 2008 and 2022. Each of the three surgeons consistently employed a distinct strategy for the management of these fractures: retention of the primary metaphyseal-engaging implant and placement of CCs; exchange to a modular, tapered-fluted stem (MTF); or exchange to a fully-coated, diaphyseal-engaging stem (FC). Stem subsidence was then evaluated on standing anteroposterior pelvis radiographs at three months and one year postoperatively. Postoperative medical and surgical complication rates were evaluated.
Results:
A total of fifteen patients were treated with CC, 15 with MTF, and 20 with FC. At three-month follow-up, mean stem subsidence was 0.43 ± 0.08 mm, 1.47 ± 0.36 mm, and 0.68 ± 0.39 mm for CC, MTF, and FC cohorts, respectively (P = .323). At one-year, mean stem subsidence was 0.70 ± 0.08 mm, 1.74 ± 0.69 mm, and 1.88 ± 0.90 mm for the CC, MTF, and FC cohorts, respectively (P = .485). Medical complications included 2 venous thromboembolic events (4%) within 90 days of surgery. There were 6 reoperations (12%); 3 (6%) for acute periprosthetic joint infection (all within the FC cohort); 2 (4%) for postoperative periprosthetic fractures (one fracture distal to the stem in the FC cohort and one fracture at the level of the stem in the MTF cohort), and 1 (2%) closed reduction for instability (within the CC cohort).
Conclusions:
The three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence; however, the risk of reoperation was much higher than expected.
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