The suitability of an uncemented hydroxyapatite coated (HAC) hip hemiarthroplasty stem for intra-capsular femoral neck fractures in osteoporotic elderly patients: the Metaphyseal-Diaphyseal index, a solution to preventing intra-operative periprosthetic fracture

Abstract

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.A 5 year prospective cohort of 560 consecutive patients, undergoing hemiarthroplasty (cemented or uncemented), was evaluated. A nested case-control study to determine risk factors affecting intra-operative fracture was carried out.The Vancouver Classification was used to classify periprosthetic fracture.The MDI score was calculated using radiographs from the uncemented group. As a control (gold standard), Yeung et al's Canal Bone Ratio (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.Four hundred and seven uncemented and one hundred and fifty-three cemented stems were implanted. The use of uncemented implants was the main risk factor for intra-operative periprosthetic fracture.Sixty-two periprosthetic fractures occurred in the uncemented group (15.2%), nine 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 and 90 day mortality 19.7%, P < 0.03.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%. Multivariate regression 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.JRI uncemented hemiarthroplasty has a significantly higher intra-operative fracture rate. We recommend cemented arthroplasty for hip fractures. We propose a radiographic system that may allow surgeons to select patients who are good candidates for uncemented arthroplasty, but it needs prospective validation.

Risk Factors for Intraoperative Proximal Femoral Fracture During Primary Cementless THA

“…Picture archiving and communication systems were used in every case, and the Noble classification, Dorr classification, and Metaphyseal-Diaphyseal Index score were used to evaluate the anatomy and morphologic features of the proximal femur (Figure 1). [7][8][9] Noble et al 7 used the canal flare index to describe the shape of the proximal femur: canal flare index scores of less than 3.0 are described as stovepipe-shaped canals, scores of 3.0 to 4.7 are described as normal canals, and scores of 4.8 to 6.5 are described as champagne flute-shaped canals ( Figure 1).…”

“…quality and morphologic features to predict suboptimal femoral morphologic features and a high chance of periprosthetic fracture in osteoporotic femurs of poor bone quality, where a cementless prosthesis would be contraindicated (Figure 1). 9 Radiologic measurements were reanalyzed by the same observer (H.C.) to determine intraobserver agreement and by another observer (Y.L.) to determine interobserver agreement.…”

“…Radiologic measurements of the proximal femur according to Noble et al7 A, femoral head offset; B, femoral head diameter; C, femoral head position; D, canal width 20 mm above the mid-lesser trochanter line; E, canal width at the mid-lesser trochanter line; F, canal width 20 mm below the mid-lesser trochanter line; G1 and G2, the 2 cortical thicknesses at the same level as F; H, isthmus diameter; I, neck-shaft angle; J, isthmus position below the mid-lesser trochanter line. The canal flare index defined by Noble et al7 is D/H; the Metaphyseal-Diaphyseal Index defined by Chana et al9 is D÷F/(G1+G2) (A). Radiologic measurements of the proximal femur: canal-to-calcar ratio (X/Y) and cortical index [(Z-X)/Z] (B).…”

Synchronized intermittent mandatory ventilation mode based on deep sedation combined with nerve block improve postoperative pulmonary function in elderly patients undergoing hip arthroplasty:a randomized controlled trial

“…Hip arthroplasty is currently the gold standard for the treatment of femoral neck fractures in elderly patients [2]. With the continuing development of surgical techniques and the improvement in artificial joint materials, the incidence of surgery-related complications in hip arthroplasty has gradually decreased [16].…”

Total hip replacement in osteoarthritis: the role of bone metabolism and its complications

“…Intraoperative radiographs should be performed to ensure that the stem appears stable and that the synthesis is reliable. Prevention of these fractures is the best target, and a careful preoperative patient assessment must be performed (14). There are no absolute age limit or weight restriction for total hip replacement.…”