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1.  Are Gender, Comorbidity and Obesity Risk factors for Postoperative Periprosthetic Fractures Following Primary Total Hip Replacement? 
The Journal of arthroplasty  2012;28(1):126-131.e2.
We studied the frequency and patient risk factors for postoperative periprosthetic fractures after primary total hip replacement (THR). With a mean follow-up of 6.3 years, 305 postoperative periprosthetic fractures occurred in 14,065 primary THRs. In multivariable-adjusted Cox regression analyses, female gender (Hazard ratio [HR], 1.48;95% confidence interval [CI]:1.17–1.88), Deyo-Charlson comorbidity score of 2 (HR, 1.74 for score of 2;95% CI: 1.25–2.43) or 3 or higher (HR, 1.71;95% CI: 1.26–2.32), ASA class of 2 (HR, 1.84;95% CI: 0.90–3.76), 3 (HR, 2.45;95% CI: 1.18–5.1) or 4 or higher (HR, 2.68;95% CI: 0.70–10.28) were significantly associated with higher risk/hazard and cemented implant with lower hazard (HR, 0.68; 95% CI: 0.54–0.87) of postoperative periprosthetic fractures. Interventions targeted at optimizing comorbidity management may decrease postoperative fractures after THR.
PMCID: PMC3414633  PMID: 22552223
2.  Patient factors Predict Periprosthetic Fractures Following Revision Total Hip Replacement 
The Journal of arthroplasty  2012;27(8):1507-1512.
We assessed important patient risk factors for postoperative periprosthetic fractures after revision total hip replacement (THR) using prospectively collected Institutional Joint Registry data. We used univariate and multivariable-adjusted Cox regression analyses. There were 330 postoperative periprosthetic fractures after 6,281 revision THRs. In multivariable-adjusted analyses, hazard [95% confidence interval] of periprosthetic fracture was higher for: women, 1.66 [1.32, 2.08], p<0.001; higher Deyo-Charlson comorbidity index of 2, 1.46 (1.03, 2.07) and index of 3+, 2.01 (1.48, 2.73), overall p<0.001; and operative diagnosis, especially previous non-union, 5.76 (2.55, 13.02), overall p<0.001. Hazard was lower in 61–70 year old, 0.64 (0.49, 0.84) and 71–80 year old 0.57 (0.43, 0.76), compared to <60 years (overall p<0.0001). Our study identified important modifiable and unmodifiable risk factors for fractures after revision THR.
PMCID: PMC3360118  PMID: 22342128
3.  Peptic ulcer disease and Pulmonary disease are Associated with Risk of Periprosthetic Fracture after Primary Total Knee Arthroplasty 
Arthritis care & research  2011;63(10):1471-1476.
To assess the association of specific comorbidities with periprosthetic fractures after primary total knee replacement (TKA)
We used the prospectively collected data in the Mayo Clinic Total Joint Registry from 1989-2008 on all patients who had undergone primary TKA. The outcome of interest was postoperative periprosthetic fractures during the follow-up. Main predictors of interest were comorbidities grouped from the validated Deyo-Charlson index. Multivariable-adjusted Cox regression analyses adjusted for gender, age, body mass index (BMI), American Society of Anesthesiology (ASA) class, operative diagnosis and implant fixation. Hazard ratios and 95% confidence intervals were calculated.
We included 17,633 primary TKAs with a mean follow-up of 6.3 years. The mean age was 68 years, 55% were women and mean BMI was 31. There were 188 postoperative periprosthetic fractures on postoperative day one or later; 162 fractures (86%) occurred postoperative day 90 day or later. In multivariable analyses that simultaneously adjusted for all comorbidities and other variables (age, gender, BMI, ASA, operative diagnosis, cement status), two conditions were significantly associated with increased hazard of postoperative periprosthetic fractures: peptic ulcer disease, hazard ratio of 1.87 (95% confidence interval:1.28, 2.75; p=0.0014); and chronic obstructive pulmonary disease (COPD) hazard ratio of 1.62 (95% confidence interval:1.10, 2.40; p=0.02).
Peptic ulcer disease and COPD are associated with higher risk of periprosthetic fractures after primary TKA. This may be related to the disease or their treatments, which needs further study. Identification of specific risk factor may allow for implementation of intervention strategies to reduce this risk.
PMCID: PMC3183369  PMID: 21748860
Total knee arthroplasty; total knee replacement; periprosthetic fracture; predictors; risk factors; comorbidity; Primary TKA
4.  Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective 
To examine the rates and predictors of deep periprosthetic infections after primary total shoulder arthroplasty (TSA).
We used prospectively collected data on all primary TSA patients from 1976-2008 at Mayo Clinic Medical Center. We estimated survival free of deep periprosthetic infections after primary TSA using Kaplan-Meier survival. Univariate and multivariable Cox regression was used to assess the association of patient-related factors (age, gender, body mass index), comorbidity (Deyo-Charlson index), American Society of Anesthesiologists class, implant fixation, and underlying diagnosis with risk of infection.
A total of 2,207 patients, with a mean age of 65 years (SD, 12 years), 53% of whom were women, underwent 2,588 primary TSAs. Mean follow-up was 7 years (SD, 6 years), and the mean body mass index was 30 kg/m2 (SD, 6 kg/m2). The American Society of Anesthesiologists class was 1 or 2 in 61% of cases. Thirty-two confirmed deep periprosthetic infections occurred during follow-up. In earlier years, Staphylococcus predominated; in recent years, Propionibacterium acnes was almost as common. The 5-, 10-, and 20-year prosthetic infection–free rates were 99.3% (95% confidence interval [CI], 98.9-99.6), 98.5% (95% CI, 97.8-99.1), and 97.2% (95% CI, 96.0-98.4), respectively. On multivariable analysis, a male patient had a significantly higher risk of deep periprosthetic infection (hazard ratio, 2.67 [95% CI, 1.22-5.87]; P =.01) and older age was associated with lower risk (hazard ratio, 0.97 [95% CI, 0.95-1.00] per year; P =.05).
The periprosthetic infection rate was low at 20-year follow-up. Male gender and younger age were significant risk factors for deep periprosthetic infections after TSA. Future studies should investigate whether differences in bone morphology, medical comorbidity, or other factors are underlying these associations.
PMCID: PMC3586318  PMID: 22516570
Total shoulder arthroplasty; periprosthetic infections
5.  Prevalence and risk factors for periprosthetic fracture in older recipients of total hip replacement: a cohort study 
The growing utilization of total joint replacement will increase the frequency of its complications, including periprosthetic fracture. The prevalence and risk factors of periprosthetic fracture require further study, particularly over the course of long-term follow-up. The objective of this study was to estimate the prevalence and risk factors for periprosthetic fractures occurring in recipients of total hip replacement.
We identified Medicare beneficiaries who had elective primary total hip replacement (THR) for non-fracture diagnoses between July 1995 and June 1996. We followed them using Medicare Part A claims data through 2008. We used ICD-9 codes to identify periprosthetic femoral fractures occurring from 2006–2008. We used the incidence density method to calculate the annual incidence of these fractures and Cox proportional hazards models to identify risk factors for periprosthetic fracture. We also calculated the risk of hospitalization over the subsequent year.
Of 58,521 Medicare beneficiaries who had elective primary THR between July 1995 and June 1996, 32,463 (55%) survived until January 2006. Of these, 215 (0.7%) developed a periprosthetic femoral fracture between 2006 and 2008. The annual incidence of periprosthetic fracture among these individuals was 26 per 10,000 person-years. In the Cox model, a greater risk of periprosthetic fracture was associated with having had a total knee replacement (HR 1.82, 95% CI 1.30, 2.55) or a revision total hip replacement (HR1.40, 95% CI 0.95, 2.07) between the primary THR and 2006. Compared to those without fractures, THR recipients who sustained periprosthetic femoral fracture had three-fold higher risk of hospitalization in the subsequent year (89% vs. 27%, p < 0.0001).
A decade after primary THR, periprosthetic fractures occur annually in 26 per 10,000 persons and are especially frequent in those with prior total knee or revision total hip replacements.
PMCID: PMC4033675  PMID: 24885707
Hip replacement; Periprosthetic fracture; Fracture; Implant; Risk factor; Epidemiology
6.  Periprosthetic Vancouver type B1 and C fractures treated by locking-plate osteosynthesis 
Acta Orthopaedica  2012;83(6):648-652.
Background and purpose
Historically, the treatment of periprosthetic femoral fractures (PFFs) has been associated with a high frequency of complications and reoperations. The preferred treatment is internal fixation, a revision of the femoral stem, or a combination of both. An improved understanding of plate use during internal fixation, and the introduction of locking-plate osteosynthesis may lead to improved outcome. We evaluated the outcome of Vancouver type B1 and C PFFs treated by locking-plate osteosynthesis, by assessing rates of fracture union and reoperations and by analyzing failure cases.
Patients and methods
From 2002 through 2011, 58 consecutive patients (60 fractures) with low-energy PFF around or below a stable femoral stem, i.e. Vancouver type B1 and C fractures, underwent osteosynthesis with a locking plate. All patients had a total hip replacement (THR). They were followed up clinically and radiographically, with 6 weeks between visits, until fracture union or until death. Fracture union was evaluated 6 months postoperatively.
At a median follow-up time of 23 (0–121) months after PFF, 8 patients (8 fractures) had been reoperated due either to infection (n = 4), failure of fixation (n = 3), or loosening of the femoral stem (n = 1). All the patients who had been followed up for at least 6 months—and who did not undergo reoperation or die—went on to fracture union (n = 43).
Locking-plate osteosynthesis of periprosthetic Vancouver type B1 and C fractures gives good results regarding fracture union. It appears that spanning of the prosthesis to avoid stress-rising areas is important for successful treatment. Infection is the major cause of failure.
PMCID: PMC3555447  PMID: 23140109
7.  Early Periprosthetic Metastasis Following Total Hip Replacement in a Patient With Breast Carcinoma: A Case Report and Review of Literature 
Early periprosthetic osteolysis following total hip replacement (THR) as a result of septic etiology has been well understood. Periprosthetic bone loss as a result of metastatic infiltration is an uncommon and infrequent cause of early, progressive loosening of joint replacement prosthesis. Proximal femur has been the most common site of involvement compared to acetabular prosthesis. The rarity of this clinical entity can lead to delay in definitive diagnosis and management, thus affecting the final outcome. Breast is the commonest site of carcinoma in female patients despite which not many cases of periprosthetic metastasis have been reported in the literature. We present the first case of extensive, isolated periacetabular bone destruction following a THR in a 59 years old female patient with a history of breast carcinoma. Patients with known primary malignancy should be screened thoroughly before operation and should be followed regularly after joint replacement surgery to detect any metastatic foci around the prosthesis.
Periprosthetic metastasis; Total hip replacement; Breast carcinoma
PMCID: PMC3194018  PMID: 22121406
8.  Risk factors for revision surgery following Humeral Head Replacement: 1,431 shoulders over 3 decades 
Assess long-term risk of revision surgery and its predictors after undergoing humeral head replacement (HHR).
We used prospectively collected data from the Mayo Clinic Total Joint registry and other institutional electronic databases. Revision-free survival for HHR at 5-, 10- and 20-years was calculated using Kaplan-Meier survival analysis. We used univariate and multivariable-adjusted Cox regression analyses to examine the association of age, gender, body mass index (BMI), comorbidity assessed by Deyo-Charlson index, American Society of Anesthesiologist (ASA) class, implant fixation (cemented versus not) and underlying diagnosis with the risk of revision surgery. Hazard ratio with 95% confidence interval (CI) and p-values are presented.
1,359 patients underwent 1,431 shoulder HHRs during the study period, 1976–2008. The average age was 63 years, 63% were female, mean BMI was 28 kg/m2 and 60% implants were cemented. 114 HHRs were revised during the follow-up. At 5-, 10- and 20-years, the shoulder implant survival was 93.6% (95% CI, 92.1%–95%), 90% (95% CI, 88%–92%) and 85% (95% CI, 81.8%–88.4%) respectively. In multivariable-adjusted analyses, older age was associated with lower hazard of revision, hazard ratio, 0.97 (95% CI, 0.96–0.99; p-value<0.001) and higher BMI with higher hazard ratio of 1.04 (95% CI, 1.01–1.08; p-value=0.02).
Long-term survival of HHR at 20-years was excellent. Obesity and younger age are risk factors for higher revision rate after HHR. Further studies should investigate the biologic rationale for these important associations. Surgeons can discuss these differences in revision risk with patients, especially in young obese patients.
PMCID: PMC3257407  PMID: 21982347
Shoulder hemiarthroplasty; humeral head replacement; revision; obesity; age
9.  BMPs in periprosthetic tissues around aseptically loosened total hip implants 
Acta Orthopaedica  2010;81(4):420-426.
Background and purpose
Primary and dynamically maintained periprosthetic bone formation is essential for osseointegration of hip implants to host bone. Bone morphogenetic proteins (BMPs) play a role in osteoinductive bone formation. We hypothesized that there is an increased local synthesis of BMPs in the synovial membrane-like interface around aseptically loosened total hip replacement (THR) implants, as body attempts to generate or maintain implant fixation.
Patients and methods
We compared synovial membrane-like interface tissue from revised total hip replacements (rTHR, n = 9) to osteoarthritic control synovial membrane samples (OA, n = 11. Avidin-biotin-peroxidase complex staining and grading of BMP-2, BMP-4, BMP-6, and BMP-7 was done. Immunofluorescence staining was used to study BMP proteins produced by mesenchymal stromal/stem cells (MSCs) and osteoblasts.
Results and interpretation
All BMPs studied were present in the synovial lining or lining-like layer, fibroblast-like stromal cells, interstitial macrophage-like cells, and endothelial cells. In OA and rTHR samples, BMP-6 positivity in cells, inducible by the proinflammatory cytokines tumor necrosis factor−α and interleukin-1β, predominated over expression of other BMPs. Macrophage-like cells positive for BMP-4, inducible in macrophages by stimulation with particles, were more frequent around loosened implants than in control OA samples, but apparently not enough to prevent loosening. MSCs contained BMP-2, BMP-4, BMP-6, and BMP-7, but this staining diminished during osteogenesis, suggesting that BMPs are produced by progenitor cells in particular, probably for storage in the bone matrix.
PMCID: PMC2917563  PMID: 20515435
10.  Favourable mid-term results of the VerSys CT polished cemented femoral stem for total hip arthroplasty 
International Orthopaedics  2006;30(5):381-386.
We evaluated the mid-term clinical and radiographical performance of a cohort of patients who underwent primary total hip replacement with a modern, forged cobalt–chrome, polished cemented femoral stem with proximal and distal centralisation. Sixty-seven patients with 73 hybrid total hip replacements were followed up clinically and radiographically for an average of 6.1 years (4–8.5). No patient was lost. No hips required revision, and all stems are radiographically well-fixed. Four hips developed localised osteolysis: one at the site of a proximal periprosthetic fracture, another at the level of a lateral femoral window of a previous core decompression, the third at the mid third of the femoral component, and the fourth on the greater trochanter, associated with accelerated polyethylene wear. This modern polished stem yielded excellent, predictable clinical and radiographic results at an intermediate follow-up.
PMCID: PMC3172773  PMID: 16575608
11.  Predictive value of Medicare claims data for identifying revision of index hip replacement was modest 
Journal of clinical epidemiology  2010;64(5):10.1016/j.jclinepi.2010.05.005.
To determine the positive predictive value of Medicare claims for identifying revision of total hip replacement (THR), a frequent marker of THR quality and outcome.
Study Design and Setting
We obtained Medicare Part A (Hospital) claims from seven states on patients that had primary THR from July 1995 through June 1996. We searched claims to determine whether these THR recipients had a subsequent revision THR through December 2006. We selected a sample of subjects with codes indicating both index primary and subsequent revision THR. We obtained medical records for both procedures to establish whether the revision occurred on the same side as index primary THR.
Three hundred seventy-four subjects had codes indicating primary THR in 1995–96 and subsequent revision. Seventy-one percent (95% confidence interval: 66, 76) of the revisions were performed on the index joint and would be correctly attributed as revisions of the index THR, using Medicare Claims data.
Claims data on revision THR that do not contain information on the side that was operated on are ambiguous with respect to whether the revision was performed on the index or contralateral side. Claims-based analyses of revisions after an index THR should acknowledge and adjust for this source of potential misclassification.
PMCID: PMC3886276  PMID: 20800448
Total hip replacement; Revision; Administrative data; Medicare claims; Misclassification; Accuracy
12.  Outcomes following surgical treatment of periprosthetic femur fractures: a single centre series 
Canadian Journal of Surgery  2014;57(3):209-213.
Periprosthetic femoral fracture after total hip arthroplasty (THA) is an increasing clinical problem and a challenging complication to treat surgically. The aim of this retrospective study was to review the treatment of periprosthetic fractures and the complication rate associated with treatment at our institution.
We reviewed the cases of patients with periprosthetic femoral fractures treated between January 2004 and June 2009. We used the Vancouver classification to assess fracture types, and we identified the surgical interventions used for these fracture types and the associated complications.
We treated 45 patients with periprosthetic femoral fractures during the study period (15 men, 30 women, mean age 78 yr). Based on Vancouver classification, 2 patients had AL fractures, 9 had AG, 15 had B1, 24 had B2, 2 had B3 and 4 had C fractures. Overall, 82% of fractures united with a mean time to union of 15 (range 2–64) months. Fourteen patients (31%) had complications; 11 of them had a reoperation: 6 to treat an infection, 6 for nonunion and 2 for aseptic femoral component loosening.
Periprosthetic fractures are difficult to manage. Careful preoperative planning and appropriate intraoperative management in the hands of experienced surgeons may increase the chances of successful treatment. However, patients should be counselled on the high risk of complications when presenting with this problem.
PMCID: PMC4035404  PMID: 24869614
13.  Mortality After Distal Femur Fractures in Elderly Patients 
Hip fractures in the elderly are associated with high 1-year mortality rates, but whether patients with other lower extremity fractures are exposed to a similar mortality risk is not clear.
We evaluated the mortality of elderly patients after distal femur fractures; determined predictors for mortality; analyzed the effect of surgical delay; and compared survivorship of elderly patients with distal femur fractures with subjects in a matched hip fracture group.
Patients and Methods
We included 92 consecutive patients older than 60 years with low-energy supracondylar femur fractures treated between 1999 and 2009. Patient, fracture, and treatment characteristics were extracted from operative records, charts, and radiographs. Data regarding mortality were obtained from the Social Security Death Index.
Age-adjusted Charlson Comorbidity Index and a previous TKA were independent predictors for decreased survival. Congestive heart failure, dementia, renal disease, and history of malignant tumor led to shorter survival times. Patients who underwent surgery more than 4 days versus 48 hours after admission had greater 6-month and 1-year mortality risks. No differences in mortality were found comparing patients with native distal femur fractures with patients in a hip fracture control group.
Periprosthetic fractures and fractures in patients with dementia, heart failure, advanced renal disease, and metastasis lead to reduced survival. The age-adjusted Charlson Comorbidity Index may serve as a useful tool to predict survival after distal femur fractures. Surgical delay greater than 4 days increases the 6-month and 1-year mortality risks. Mortality after native fractures of the distal femur in the geriatric population is high and similar to mortality after hip fractures.
Level of Evidence
Level II, prognostic study. See the guidelines online for a complete description of evidence.
PMCID: PMC3048257  PMID: 20830542
14.  Ninety day mortality and its predictors after primary shoulder arthroplasty: an analysis of 4,019 patients from 1976-2008 
Examine 90-day postoperative mortality and its predictors following shoulder arthroplasty
We identified vital status of all adults who underwent primary shoulder arthroplasty (Total shoulder arthroplasty (TSA) or humeral head replacement (HHR)) at the Mayo Clinic from 1976-2008, using the prospectively collected information from Total Joint Registry. We used univariate logistic regression models to assess the association of gender, age, body mass index, American Society of Anesthesiologist (ASA) class, Deyo-Charlson comorbidity index, an underlying diagnosis and implant fixation with odds of 90-day mortality after TSA or HHR. Multivariable models additionally adjusted for the type of surgery (TSA versus HHR). Adjusted Odds ratio (OR) with 95% confidence interval (CI) were calculated.
Twenty-eight of the 3, 480 patient operated died within 90-days of shoulder arthroplasty (0.8%). In multivariable-adjusted analyses, the following factors were associated with significantly higher odds of 90-day mortality: higher Deyo-Charlson index (OR, 1.54; 95% CI:1.39, 1.70; p < 0.001); a diagnosis of tumor (OR, 16.2; 95%CI:7.1, 36.7); and ASA class III (OR, 3.57; 95% CI:1.29, 9.91; p = 0.01) or class IV (OR, 13.4; 95% CI:2.44, 73.86; p = 0.003). BMI ≥ 30 was associated with lower risk of 90-day mortality (OR, 0.25; 95% CI:0.08, 0.78). In univariate analyses, patients undergoing TSA had significantly lower 90-day mortality of 0.4% (8/2, 580) compared to 1% in HHR (20/1, 411) (odds ratio, 0.22 (95% CI: 0.10, 0.50); p = 0.0003).
90-day mortality following shoulder arthroplasty was low. An underlying diagnosis of tumor, higher comorbidity and higher ASA class were risk factors for higher 90-day mortality, while higher BMI was protective. Pre-operative comorbidity management may impact 90-day mortality following shoulder arthroplasty. A higher unadjusted mortality in patients undergoing TSA versus HHR may indicate the underlying differences in patients undergoing these procedures.
PMCID: PMC3206490  PMID: 21992475
mortality; shoulder arthroplasty; humeral head replacement; shoulder hemiarthroplasty
15.  Prospective and comparative study of the anterolateral mini-invasive approach versus minimally invasive posterior approach for primary total hip replacement. Early results 
International Orthopaedics  2006;31(5):597-603.
The interest in minimally invasive approaches for total hip replacement (THR) has not waned in any way. We carried out a prospective and comparative study in order to analyse the interest of the anterolateral minimal invasive (ALMI) approach in comparison with a minimally invasive posterior (MIP) approach. A group of 35 primary THRs with a large head using the ALMI approach was compared with a group of 43 THR performed through a MIP approach. The groups were not significantly different with respect to age, sex, bony mass index, ASA score, Charnley class, diagnoses and preoperative Womac index and PMA score. The preoperative Harris Hip Score was significantly lower in the ALMI group. The duration of surgical procedure was longer and the calculated blood loss more substantial in the ALMI group. The perioperative complications were significantly more frequent in this group, with four greater trochanter fractures, three false routes, one calcar fracture, and two metal back bascules versus one femoral fracture in MIP group. Other postoperative data (implant positioning, morphine consumption, length of hospital stay, type of discharge) are comparable, such as the early functional results. No other complication has been noted during the first 6 months. The ALMI approach uses the intermuscular interval between the tensor fascia lata and the gluteus medius. It leaves intact the abductor muscles, the posterior capsule and the short external rotators. The early clinical results are excellent, despite the initial complications related to the initial learning curve for this approach and the use of a large head. The stability and the absence of muscular damage should permit acceleration of the postoperative rehabilitation in parallel with less perioperative complications after the initial learning curve.
PMCID: PMC2266652  PMID: 17053875
16.  Perioperative Hyperglycemia and Postoperative Infection after Lower Limb Arthroplasty 
One of the most serious complications after major orthopedic surgery is deep wound or periprosthetic joint infection. Various risk factors for infection after hip and knee replacement surgery have been reported, including patients' comorbidities and surgical technique factors. We investigated whether hyperglycemia and diabetes mellitus (DM) are associated with infection that requires surgical intervention after total hip and knee arthroplasty.
We reviewed our computerized database for elective primary total hip and knee arthroplasty from 2000 to 2008. Demographic information, past medical history of patients, perioperative biochemistry, and postoperative complications were reviewed.
Patients were divided into two groups: infected group (101 patients who had surgical intervention for infection at our institution within 2 years after primary surgery) and noninfected group (1847 patients with no intervention with a minimum of one year follow-up. The data were analyzed using t, chi-squared, and Fisher's exact tests.
There were significantly more diabetes patients in the infected group compared with the noninfected group (22% versus 9%, p < .001). Infected patients had significantly higher perioperative blood glucose (BG) values: preoperative BG (112 ± 36 versus 105 ± 31 mg/dl, p = .043) and postoperative day (POD) 1 BG (154 ± 37 versus 138 ± 31 mg/dl, p < .001). Postoperative morning hyperglycemia (BG >200 mg/dl) increased the risk for the infection more than two-fold. Non-DM patients were three times more likely to develop the infection if their morning BG was >140 mg/dl on POD 1, p = .001. Male gender, higher body mass index, knee arthroplasty, longer operative time and hospital stay, higher comorbidity index, history of myocardial infarction, congestive heart failure, and renal insufficiency were also associated with the infection.
Diabetes mellitus and morning postoperative hyperglycemia were predictors for postoperative infection following total joint arthroplasty. Even patients without a diagnosis of DM who developed postoperative hyperglycemia had a significantly increased risk for the infection.
PMCID: PMC3125936  PMID: 21527113
blood glucose; diabetes mellitus; hip and knee arthroplasty; infection; orthopedic surgery
17.  A population-based study of prevalence and hospital charges in total hip and knee replacement 
International Orthopaedics  2008;33(4):949-954.
The purpose of this study was to explore the increasing prevalence of factors affecting hospital charges for primary total hip replacement/total knee replacement (THR/TKR). This study analysed 37,918 THR and 76,727 TKR procedures performed in Taiwan from 1996 to 2004. Odds ratio (OR) and effect size (ES) were calculated to assess the relative change rate. Multiple regression models were employed to predict hospital charges. The following factors were associated with increased hospital charges: age younger than 65 years old; increased disease severity (Charlson comorbidity index [CCI] = 1 or ≥2); absence of primary diagnoses of osteoarthritis (OA), rheumatoid arthritis (RA), avascular necrosis (AVN); treatment at a hospital or by a surgeon performing a high volume of operations; and longer average length of stay (ALOS). The Bureau of National Health Insurance (BNHI) should ensure that surgeons take precautionary measures to minimise complications and maximise quality of life after surgery. Use of joint prostheses from different manufacturers can reduce costs without compromising patient satisfaction.
PMCID: PMC2898996  PMID: 18612638
18.  Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study 
BMJ : British Medical Journal  2005;331(7529):1374.
Objectives To evaluate postoperative medical complications and the association between these complications and mortality at 30 days and one year after surgery for hip fracture and to examine the association between preoperative comorbidity and the risk of postoperative complications and mortality.
Design Prospective observational cohort study.
Setting University teaching hospital.
Participants 2448 consecutive patients admitted with an acute hip fracture over a four year period. We excluded 358 patients: all those aged < 60; those with periprosthetic fractures, pathological fractures, and fractures treated without surgery; and patients who died before surgery.
Interventions Routine care for hip fractures.
Main outcome measures Postoperative complications and mortality at 30 days and one year.
Results Mortality was 9.6% at 30 days and 33% at one year. The most common postoperative complications were chest infection (9%) and heart failure (5%). In patients who developed postoperative heart failure mortality was 65% at 30 days (hazard ratio 16.1, 95% confidence interval 12.2 to 21.3). Of these patients, 92% were dead by one year (11.3, 9.1 to 14.0). In patients who developed a postoperative chest infection mortality at 30 days was 43% (8.5, 6.6 to 11.1). Significant preoperative variables for increased mortality at 30 days included the presence of three or more comorbidities (2.5, 1.6 to 3.9), respiratory disease (1.8, 1.3 to 2.5), and malignancy (1.5, 1.01 to 2.3).
Conclusions In elderly people with hip fracture, the presence of three or more comorbidities is the strongest preoperative risk factor. Chest infection and heart failure are the most common postoperative complications and lead to increased mortality. These groups offer a clear target for specialist medical assessment.
PMCID: PMC1309645  PMID: 16299013
19.  Increased risk of revision in patients with non-traumatic femoral head necrosis 
Acta Orthopaedica  2014;85(1):11-17.
Background and purpose
Previous studies of patients who have undergone total hip arthroplasty (THA) due to femoral head necrosis (FHN) have shown an increased risk of revision compared to cases with primary osteoarthritis (POA), but recent studies have suggested that this procedure is not associated with poor outcome. We compared the risk of revision after operation with THA due to FHN or POA in the Nordic Arthroplasty Register Association (NARA) database including Denmark, Finland, Norway, and Sweden.
Patients and methods
427,806 THAs performed between 1995 and 2011 were included. The relative risk of revision for any reason, for aseptic loosening, dislocation, deep infection, and periprosthetic fracture was studied before and after adjustment for covariates using Cox regression models.
416,217 hips with POA (mean age 69 (SD 10), 59% females) and 11,589 with FHN (mean age 65 (SD 16), 58% females) were registered. The mean follow-up was 6.3 (SD 4.3) years. After 2 years of observation, 1.7% in the POA group and 3.0% in the FHN group had been revised. The corresponding proportions after 16 years of observation were 4.2% and 6.1%, respectively. The 16-year survival in the 2 groups was 86% (95% CI: 86–86) and 77% (CI: 74–80). After adjusting for covariates, the relative risk (RR) of revision for any reason was higher in patients with FHN for both periods studied (up to 2 years: RR = 1.44, 95% CI: 1.34–1.54; p < 0.001; and 2–16 years: RR = 1.25, 1.14–1.38; p < 0.001).
Patients with FHN had an overall increased risk of revision. This increased risk persisted over the entire period of observation and covered more or less all of the 4 most common reasons for revision.
PMCID: PMC3940986  PMID: 24359026
20.  Metal-on-Metal Total Hip Resurfacing Arthroplasty 
Executive Summary
The objective of this review was to assess the safety and effectiveness of metal on metal (MOM) hip resurfacing arthroplasty for young patients compared with that of total hip replacement (THR) in the same population.
Clinical Need
Total hip replacement has proved to be very effective for late middle-aged and elderly patients with severe degenerative diseases of the hips. As indications for THR began to include younger patients and those with a more active life style, the longevity of the implant became a concern. Evidence suggests that these patients experience relatively higher rates of early implant failure and the need for revision. The Swedish hip registry, for example, has demonstrated a survival rate in excess of 80% at 20 years for those aged over 65 years, whereas this figure was 33% by 16 years in those aged under 55 years.
Hip resurfacing arthroplasty is a bone-conserving alternative to THR that restores normal joint biomechanics and load transfer. The technique has been used around the world for more than 10 years, specifically in the United Kingdom and other European countries.
The Technology
Metal-on-metal hip resurfacing arthroplasty is an alternative procedure to conventional THR in younger patients. Hip resurfacing arthroplasty is less invasive than THR and addresses the problem of preserving femoral bone stock at the initial operation. This means that future hip revisions are possible with THR if the initial MOM arthroplasty becomes less effective with time in these younger patients. The procedure involves the removal and replacement of the surface of the femoral head with a hollow metal hemisphere, which fits into a metal acetabular cup.
Hip resurfacing arthroplasty is a technically more demanding procedure than is conventional THR. In hip resurfacing, the femoral head is retained, which makes it much more difficult to access the acetabular cup. However, hip resurfacing arthroplasty has several advantages over a conventional THR with a small (28 mm) ball. First, the large femoral head reduces the chance of dislocation, so that rates of dislocation are less than those with conventional THR. Second, the range of motion with hip resurfacing arthroplasty is higher than that achieved with conventional THR.
A variety of MOM hip resurfacing implants are used in clinical practice. Six MOM hip resurfacing implants have been issued licences in Canada.
Review Strategy
A search of electronic bibliographies (OVID Medline, Medline In-Process and Other Non-Indexed Citations, Embase, Cochrane CENTRAL and DSR, INAHTA) was undertaken to identify evidence published from Jan 1, 1997 to October 27, 2005. The search was limited to English-language articles and human studies. The literature search yielded 245 citations. Of these, 11 met inclusion criteria (9 for effectiveness, 2 for safety).
The result of the only reported randomized controlled trial on MOM hip resurfacing arthroplasty could not be included in this assessment, because it used a cemented acetabular component, whereas in the new generation of implants, a cementless acetabular component is used. After omitting this publication, only case series remained.
Summary of Findings
Health Outcomes
The Harris hip score and SF-12 are 2 measures commonly used to report health outcomes in MOM hip resurfacing arthroplasty studies. Other scales used are the Oxford hip score and the University of California Los Angeles hip score.
The case series showed that the mean revision rate of MOM hip resurfacing arthroplasty is 1.5% and the incidence of femoral neck fracture is 0.67%. Across all studies, 2 cases of osteonecrosis were reported. Four studies reported improvement in Harris hip scores. However, only 1 study reported a statistically significant improvement. Three studies reported improvement in SF-12 scores, of which 2 reported a significant improvement. One study reported significant improvement in UCLA hip score. Two studies reported postoperative Oxford hip scores, but no preoperative values were reported.
None of the reviewed studies reported procedure-related deaths. Four studies reported implant survival rates ranging from 94.4% to 99.7% for a follow-up period of 2.8 to 3.5 years. Three studies reported on the range of motion. One reported improvement in all motions including flexion, extension, abduction-adduction, and rotation, and another reported improvement in flexion. Yet another reported improvement in range of motion for flexion abduction-adduction and rotation arc. However, the author reported a decrease in the range of motion in the arc of flexion in patients with Brooker class III or IV heterotopic bone (all patients were men).
Safety of Metal-on-Metal Hip Resurfacing Arthroplasty
There is a concern about metal wear debris and its systemic distribution throughout the body. Detectable metal concentrations in the serum and urine of patients with metal hip implants have been described as early as the 1970s, and this issue is still controversial after 35 years.
Several studies have reported high concentration of cobalt and chromium in serum and/or urine of the patients with metal hip implants. Potential toxicological effects of the elevated metal ions have heightened concerns about safety of MOM bearings. This is of particular concern in young and active patients in whom life expectancy after implantation is long.
Since 1997, 15 studies, including 1 randomized clinical trial, have reported high levels of metal ions after THR with metal implants. Some of these studies have reported higher metal levels in patients with loose implants.
Adverse Biological Effects of Cobalt and Chromium
Because patients who receive a MOM hip arthroplasty are shown to be exposed to high concentrations of metallic ions, the Medical Advisory Secretariat searched the literature for reports of adverse biological effects of cobalt and chromium. Cobalt and chromium make up the major part of the metal articulations; therefore, they are a focus of concern.
Risk of Cancer
To date, only one study has examined the incidence of cancer after MOM and polyethylene on metal total hip arthroplasties. The results were compared to that of general population in Finland. The mean duration of follow-up for MOM arthroplasty was 15.7 years; for polyethylene arthroplasty, it was 12.5 years. The standardized incidence ratio for all cancers in the MOM group was 0.95 (95% CI, 0.79–1.13). In the polyethylene on metal group it was 0.76 (95% CI, 0.68–0.86). The combined standardized incidence ratio for lymphoma and leukemia in the patients who had MOM THR was 1.59 (95% CI, 0.82–2.77). It was 0.59 (95% CI, 0.29–1.05) for the patients who had polyethylene on metal THR. Patients with MOM THR had a significantly higher risk of leukemia. All patients who had leukemia were aged over than 60 years.
Cobalt Cardiotoxicity
Epidemiological Studies of Myocardiopathy of Beer Drinkers
An unusual type of myocardiopathy, characterized by pericardial effusion, elevated hemoglobin concentrations, and congestive heart failure, occurred as an epidemic affecting 48 habitual beer drinkers in Quebec City between 1965 and 1966. This epidemic was directly related the consumption of a popular beer containing cobalt sulfate. The epidemic appeared 1 month after cobalt sulfate was added to the specific brewery, and no further cases were seen a month after this specific chemical was no longer used in making this beer. A beer of the same name is made in Montreal, and the only difference at that time was that the Quebec brand of beer contained about 10 times more cobalt sulphate. Cobalt has been added to some Canadian beers since 1965 to improve the stability of the foam but it has been added in larger breweries only to draught beer. However, in small breweries, such as those in Quebec City, separate batches were not brewed for bottle and draught beer; therefore, cobalt was added to all of the beer processed in this brewery.
In March 1966, a committee was appointed under the chairmanship of the Deputy Minister of Health for Quebec that included members of the department of forensic medicine of Quebec’s Ministry of Justice, epidemiologists, members of Food and Drug Directorate of Ottawa, toxicologists, biomedical researchers, pathologists, and members of provincial police. Epidemiological studies were carried out by the Provincial Ministry of Health and the Quebec City Health Department.
The association between the development of myocardiopathy and the consumption of the particular brand of beer was proven. The mortality rate of this epidemic was 46.1% and those who survived were desperately ill, and recovered only after a struggle for their lives.
Similar cases were seen in Omaha (Nebraska). The epidemic started after a cobalt additive was used in 1 of the beers marketed in Nebraska. Sixty-four patients with the clinical diagnosis of alcoholic myocardiopathy were seen during an 18-month period (1964–1965). Thirty of these patients died. The first patient became ill within 1 month after cobalt was added to the beer, and the last patient was seen within 1 month of withdrawal of cobalt.
A similar epidemic occurred in Minneapolis, Minnesota. Between 1964 and 1967, 42 patients with acute heart failure were admitted to a hospital in Minneapolis, Minnesota. Twenty of these patients were drinking 6 to 30 bottles per day of a particular brand of beer exclusively. The other 14 patients also drank the same brand of beer, but not exclusively. The mortality rate from the acute illness was 18%, but late deaths accounted for a total mortality rate of 43%. Examination of the tissue from these patients revealed markedly abnormal changes in myofibrils (heart muscles), mitochondria, and sarcoplasmic reticulum.
In Belgium, a similar epidemic was reported in 1966, in which, cobalt was used in some Belgian beers. There was a difference in mortality between the Canadian or American epidemic and this series. Only 1 of 24 patients died, 1.5 years after the diagnosis. In March 1965, at an international meeting in Brussels, a new heart disease in chronic beer drinkers was described. This disease consists of massive pericardial effusion, low cardiac output, raised venous pressure, and polycythemia in some cases. This syndrome was thought to be different from the 2 other forms of alcoholic heart disease (beriberi and a form characterized by myocardial fibrosis).
The mystery of the above epidemics as stated by investigators is that the amount of cobalt added to the beer was below the therapeutic doses used for anemia. For example, 24 pints of Quebec brand of beer in Quebec would contain 8 mg of cobalt chloride, whereas an intake of 50 to 100 mg of cobalt as an antianemic agent has been well tolerated. Thus, greater cobalt intake alone does not explain the occurrence of myocardiopathy. It seems that there are individual differences in cobalt toxicity. Other features, like subclinical alcoholic heart disease, deficient diet, and electrolyte imbalance could have been precipitating factors that made these patients susceptible to cobalt’s toxic effects.
In the Omaha epidemic, 60% of the patients had weight loss, anorexia, and occasional vomiting and diarrhea 2 to 6 months before the onset of cardiac symptoms. In the Quebec epidemic, patients lost their appetite 3 to 6 months before the diagnosis of myocardiopathy and developed nausea in the weeks before hospital admission. In the Belgium epidemic, anorexia was one of the most predominant symptoms at the time of diagnosis, and the quality and quantity of food intake was poor. Alcohol has been shown to increase the uptake of intracoronary injected cobalt by 47%. When cobalt enters the cells, calcium exits; this shifts the cobalt to calcium ratio. The increased uptake of cobalt in alcoholic patients may explain the high incidence of cardiomyopathies in beer drinkers’ epidemics.
As all of the above suggest, it may be that prior chronic exposure to alcohol and/or a nutritionally deficient diet may have a marked synergistic effect with the cardiotoxicity of cobalt.
MOM hip resurfacing arthroplasty has been shown to be an effective arthroplasty procedure as tested in younger patients.
However, evidence for effectiveness is based only on 7 case series with short duration of follow-up (2.8–3.5 years). There are no RCTs or other well-controlled studies that compare MOM hip resurfacing with THR.
Revision rates reported in the MOM studies using implants currently licensed in Canada (hybrid systems, uncemented acetabular, and cemented femoral) range from 0.3% to 3.6% for a mean follow-up ranging from 2.8 to 3.5 years.
Fracture of femoral neck is not very common; it occurs in 0.4% to 2.2% of cases (as observed in a short follow-up period).
All the studies that measured health outcomes have reported improvement in Harris Hip and SF-12 scores; 1 study reported significant reduction in pain and improvement in function, and 2 studies reported significant improvement in SF-12 scores. One study reported significant improvement in UCLA Hip scores.
Concerns remain on the potential adverse effects of metal ions. Longer-term follow-up data will help to resolve the inconsistency of findings on adverse effects, including toxicity and carcinogenicity.
Ontario-Based Economic Analysis
The device cost for MOM ranges from $4,300 to $6,000 (Cdn). Traditional hip replacement devices cost about $2,000 (Cdn). Using Ontario Case Costing Initiative data, the total estimated costs for hip resurfacing surgery including physician fees, device fees, follow-up consultation, and postsurgery rehabilitation is about $15,000 (Cdn).
Cost of Total Hip Replacement Surgery in Ontario
MOM hip arthroplasty is generally recommended for patients aged under 55 years because its bone-conserving advantage enables patients to “buy time” and hence helps THRs to last over the lifetime of the patient. In 2004/2005, 15.9% of patients who received THRs were aged 55 years and younger. It is estimated that there are from 600 to 1,000 annual MOM hip arthroplasty surgeries in Canada with an estimated 100 to 150 surgeries in Ontario. Given the increased public awareness of this device, it is forecasted that demand for MOM hip arthroplasty will steadily increase with a conservative estimate of demand rising to 1,400 cases by 2010 (Figure 10). The net budget impact over a 5-year period could be $500,000 to $4.7 million, mainly because of the increasing cost of the device.
Projected Number of Metal-on-Metal Hip Arthroplasty Surgeries in Ontario: to 2010
PMCID: PMC3379532  PMID: 23074495
21.  Risk factors for revision of primary total hip replacement: Results from a national case-control study 
Arthritis care & research  2012;64(12):1879-1885.
To study risk factors for revision of primary total hip replacement (THR) in a US population-based sample.
Using Medicare claims, we identified beneficiaries from 29 US states who underwent primary THR between 7/1/1995 and 6/30/1996, and followed them through 12/31/2008. Potential cases had ICD-9 codes indicating revision THR. Each case was matched by state with one control THR recipient who was alive and unrevised when the case had revision THR. We abstracted hospital records to document potential risk factors. We examined associations between preoperative factors and revision risk using multivariate conditional logistic regression.
The analysis data set consisted of 719/836 case-control pairs with complete data for analysis variables. Factors associated with higher revision odds in multivariate models were age ≤75 at primary surgery (OR 1.52, 95% CI 1.20, 1.92), height in highest tertile (OR 1.40, 95% CI 1.06, 1.85), weight in highest tertile (OR 1.66, 95% CI 1.24, 2.22), cemented femoral component (OR 1.44, 95% CI 1.10, 1.87), prior contralateral primary THR (OR 1.36, 95% CI 1.05, 1.76), other prior orthopedic surgery (OR 1.45, 95% CI 1.13, 1.84), and living with others (versus alone; OR 1.26, 95% CI 0.99, 1.61).
This first US population-based case-control study of risk factors for revision of primary THR showed that younger, taller, and heavier patients and those receiving a cemented femoral component had greater likelihood of revision THR over twelve-year follow-up. Effects of age and body size on revision risk should be addressed by clinicians with patients considering primary THR.
PMCID: PMC3510659  PMID: 23193090
22.  Bacterial contamination of the wound during primary total hip and knee replacement 
Acta Orthopaedica  2014;85(2):159-164.
Background and purpose
Previous work has shown that despite preventive measures, intraoperative contamination of joint replacements is still common, although most of these patients seem to do well in follow-up of up to 5 years. We analyzed the prevalence and bacteriology of intraoperative contamination of primary joint replacement and assessed whether its presence is related to periprosthetic joint infection (PJI) on long-term follow-up.
Patients and methods
49 primary total hip replacements (THRs) and 41 total knee replacements (TKRs) performed between 1990 and 1991 were included in the study. 4 bacterial swabs were collected intraoperatively during each procedure. Patients were followed up for joint-related complications until March 2011.
19 of 49 THRs and 22 of 41 TKRs had at least 1 positive culture. Coagulase-negative staphylococci and Staphylococcus aureus were the most common organisms, contaminating 28 and 9 operations respectively. Where information was available, bacteria from 27 of 29 contaminated operations were susceptible to the prophylactic antibiotic administered. 13% of samples gathered before 130 min of surgery were contaminated, as compared to 35% collected after that time. 2 infections were diagnosed, both in TKRs. 1 of them may have been related to intraoperative contamination.
Intraoperative contamination was common but few infections occurred, possibly due to the effect of prophylactic antibiotics. The rate of contamination was higher with longer duration of surgery. It appears that positive results from intraoperative swabs do not predict the occurrence of PJI.
PMCID: PMC3967258  PMID: 24650025
23.  Relation between surgeon volume and risk of complications after total hip arthroplasty: propensity score matched cohort study 
Objectives To identify a cut point in annual surgeon volume associated with increased risk of complications after primary elective total hip arthroplasty and to quantify any risk identified.
Design Propensity score matched cohort study.
Setting Ontario, Canada
Participants 37 881 people who received their first primary total hip arthroplasty during 2002-09 and were followed for at least two years after their surgery.
Main outcome measure The rates of various surgical complications within 90 days (venous thromboembolism, death) and within two years (infection, dislocation, periprosthetic fracture, revision) of surgery.
Results Multivariate splines were developed to visualize the relation between surgeon volume and the risk for various complications. A threshold of 35 cases a year was identified, under which there was an increased risk of dislocation and revision. 6716 patients whose total hip arthroplasty was carried out by surgeons who had done ≤35 such procedure in the previous year were successfully matched to patients whose surgeon had carried out more than 35 procedures. Patients in the former group had higher rates of dislocation (1.9% v 1.3%, P=0.006; NNH 172) and revision (1.5% v 1.0%, P=0.03; NNH 204).
Conclusions In a cohort of first time recipients of total hip arthroplasty, patients whose operation was carried by surgeons who had performed 35 or fewer such procedures in the year before the index procedure were at increased risk for dislocation and early revision. Surgeons should consider performing 35 cases or more a year to minimize the risk for complications. Furthermore, the methods used to visualize the relationship between surgeon volume and the occurrence of complications can be easily applied in any jurisdiction, to help inform and optimize local healthcare delivery.
PMCID: PMC4032026  PMID: 24859902
24.  Predictors of pain and use of pain medications following primary Total Hip Arthroplasty (THA): 5,707 THAs at 2-years and 3,289 THAs at 5-years 
Study pain and use of pain medications and their predictors after primary Total Hip Arthroplasty (THA).
We examined whether gender, age (reference, < = 60 yrs), body mass index (BMI; reference, <25 kg/m2)), comorbidity measured by Deyo-Charlson index (5-point increase), anxiety and depression predict moderate-severe hip pain and use of pain medications 2- and 5-years after primary THA. Multivariable logistic regression adjusted for these predictors and distance from medical center, operative diagnosis, American Society of Anesthesiologists (ASA) score and implant type.
Moderate-severe pain was reported by 8.1% at 2-years and 10.8% at 5-years. Significant predictors of moderate-severe pain at 2-year follow-up were [Odds ratio (95% confidence interval)]: BMI 35-39.9, 1.8 (1.2,2.8); BMI > = 40, 1.7 (1.0,2.9); depression, 2.1 (1.4,3.0). Moderate-severe pain at 5-years was more common in patients with higher BMI: 25-29.9, 1.5 (1.1,2.1); 30-34.9, 1.8 (1.2,2.6); 35-39.9, 1.9 (1.2,3.1); and > = 40, 3.1 (1.7,5.7).
Significant predictors of NSAID use were [Odds ratio (95% confidence interval)]: female gender at 2- and 5-years, 1.4 (1.1,1.7) and 1.4 (1.1,1.8); BMI 35-39.9 at 2-years, 1.9 (1.4, 2.6) and 30-34.9 at 2-years, 1.7 (1.2,2.4); and depression at 5-years, 1.8 (1.2,2.8).
Significant predictors of opioid medication use were [Odds ratio (95% confidence interval)]: female gender at 2- and 5-years, 2.0 (1.1,3.0) and 2.4 (1.4,4.0); BMI 30-34.9 at 2-years, 2.0 (1.0,3.9); and depression at 2-years, 2.0 (1.1,3.7).
Higher BMI and depression impacted moderate-severe pain; and female gender, higher BMI and depression predicted use of pain medications at 2- and 5-years post-primary THA.
PMCID: PMC2881019  PMID: 20462458
25.  Early Experience with a Novel Nonmetallic Cable in Reconstructive Hip Surgery 
Metallic wires and cables are commonly used in primary and revision THA for fixation of periprosthetic fractures and osteotomies of the greater trochanter. These systems provide secure fixation and high healing rates but fraying, third-body generation, accelerated wear of the bearing surface, and injury to the surgical team remain concerning.
We determined the rate of cable failure, union, and complications associated with a novel, nonmetallic cerclage cable in periprosthetic fracture and osteotomy fixation during THA.
We retrospectively reviewed 29 patients who had primary and revision THAs using nonmetallic cables. Indications for use included fixation of an extended trochanteric osteotomy, intraoperative fracture of the proximal femur, strut allograft fixation, and a Vancouver B1 periprosthetic fracture of the femur. All patients were evaluated clinically and radiographically immediately postoperatively, at 3 weeks, 6 weeks, 3 months, and then annually thereafter. The minimum followup was 13 months (mean, 21 months; range, 13–30 months).
Two of the 29 patients (7%) developed a nonunion; all remaining osteotomies, fractures and allografts had healed at the time of most recent evaluation. Four patients (14%) dislocated postoperatively; two were treated successfully with closed reduction, while the other two required reoperation. We identified no evidence of breakage or other complications directly attributable to the cables.
The nonmetallic periprosthetic cables used in this series provided adequate fixation to allow for both osteotomy and fracture healing. We did not observe any complications directly related to the cables.
Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2919859  PMID: 20204557

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