“One-third to one-half of all arthroplasty failures occur within the first one to two years. And if you look at why they fail, the main cause is instability,” Moskal said.
The main causes of arthroplasty failures in the first decade, according to Moskal, is dislocation/instability, infection and periprosthetic fractures.
The data don’t lie and unfortunately the problem isn’t going to get better.
Another study, “Incidence of Projected Periprosthetic Femoral Fracture Following THA; An Analyses of International Registry Data” presented at the American Academy of Orthopaedic Surgeons annual meeting in 2014 also found that periprosthetic fractures are expected to rise by a mean 4.6% every decade (range, 4.1 to 5%).
Another study, “Epidemiology of Periprosthetic Fracture of the Femur in 32,644 primary Total Hip Arthroplasties: a 40-year Experience” published in Journal of Joint and Bone Surgery in 2016 also focused on periprosthetic fractures and these researchers found that intra-operative fractures occur 14 times more often with uncemented stems and that the majority of fractures are non-displaced calcar fractures treated with cerclage cables/wires. The fractures occurred more often in female patients older than 65 years of age and the majority required surgical intervention.
In addition, a 2010 study, “Uncemented and Cemented primary Total Hip Arthroplasty in the Swedish Hip Arthroplasty Register” in the Acta Orthopaedica reported similar data. Out of 170,413 hip arthroplasties, 17% had early post-operative fractures in uncemented stems early and 6% had late fractures in cemented stems.
The bottom line, said Moskal, is that periprosthetic fractures remain an unsolved problem. The incidence of such fractures is increasing because of the increasing number of THAs, the increasing use of cementless femoral stems and the ever aging patient population with attendant poor bone quality.
Unfortunately, operative treatment of acute fracture has a 61% complication rate, a 5% to 10% infection rate and a 23% secondary re-operation rate. Revisions are more complex because of a fresh wound and recent surgery, and therefore, many of these periprosthetic femoral fractures that occur within the first year also lead to increased patient mortality and decreased mobility.
In “Mid-Term Results of 121 Periprosthetic Femoral Fractures: Increased Failure and Mortality Within But Not After One Postoperative Year” published in the Journal of Arthroplasty in 2015, the data showed a one-year mortality rate of 13.2% and a re-revision rate of 16.5% when in first year.
Another study, “Adequate surgical treatment of periprosthetic femoral fractures following hip arthroplasty does not correlate with functional outcome and quality of life,” published in International Orthopaedics in 2015 emphasized that many of these patients do not recover preoperative ambulatory status.
Moskal, said, “Within three years of periprosthetic fracture, over 50% of patients have died and in the U.S. we are still putting in 93% of cementless stems.”
According to Moskal, all national registries show an increasing use of uncemented THA worldwide. He said, “To me, it is a ‘paradox’. Cemented THA has the lowest revision rate in patients older than 65 years and older than 75 years group.”
“We know what we are doing is not sustainable. The high prevalence of total joint replacement creates a need to effectively manage the long-term health-care requirements and reduce the burden of subsequent complications and re-operations,” he said.
