Aim

Adequate debridement of necrotic bone is of paramount importance for eradication of infection in chronic osteomyelitis. Currently, no tools are available to detect the exact amount of necrotic bone in order to optimize surgical resection. The aim of the present study was to evaluate the feasibility of an intraoperative illumination method (VELscope^®) and the correlation between intraoperative and pathohistological findings in surgically treated chronic fracture related infection patients.

Introduction: Periprosthetic fractures have long been recognized as one of the major complications after hip resurfacing arthroplasty. Both biomechanical factors and pathological changes of bone tissue might hypothetically influence its occurrence. We analyzed retrieved femoral remnants to identify possibly different fracture modes.

Material and Methods: 83 hips revised for periprosthetic fracture (134.5 days in situ±159.2) were analyzed macroscopically, contact radiographically and histologically. Most cases (80.7%) were treated for advanced stages of osteoarthritis. Hips with preoperative femoral head necrosis were not included. 49 (59.0%) patients were men (57.8 years old±8.5) and 34 (41.0%) women (55.1 years old±10.0; p=.3445). Occurrence of reactive changes and of avascular necrosis in addition to amount of osteonecrosis were used as the major histological criteria for classification of the fracture as acute biomechanical, acute postnecrotic or chronic.

Statistical analyses were performed using statistical software. Probability of Type I error was set to 5% (alpha=0.05).

Results: 37 (44.6%) femoral neck fractures (83.9 days±87.7) occurred earlier than the remaining 46 (55.4%) head fractures (174.1 days±89.7; p=.0129). 50(60.2%) remnants revealed complete osteonecrosis and were thus classified as acute postnecrotic fractures, 29 (34.9%) chronic fractures were characterized by finding of pseudoarthrosis or preformed callus and the remaining 4 (4.8%) were classified as acute mechanic. Acute mechanic fractures (17.5 days±8.0) failed earlier than both acute postnecrotic (146.3 days±181.7; p=.0049) and chronic (130.8 days±120.6; p=.0017) fractures.

Osteonecrosis was found in 81 (97.6%) hips revised after fracture (p< .0001). The vertical size of avascular necrosis in hips after acute postnecrotic fracture (21.1mm±8.5) was bigger (p< .0001) than in both chronic (7.3mm±7.3) and acute mechanic (0.9 mm±1.2) fractures.

Even though 33 (66.0%) of 50 patients with acute postnecrotic fracture were men (p=.0237), no significant differences between males and females were found with respect to age of patients (p=.3445) or duration of prosthesis implantation (p=.1232).

Conclusion: We analyzed hips revised for periprosthetic fracture after the resurfacing arthroplasty. Three distinct fracture modes of this complication could have been identified morphologically. Osteonecrosis secondary to the hip resurfacing arthroplasty appeared to be causative for more than a half of all fractures in present cohort. Mechanical and biomechanical factors related to the procedure might have possibly influenced the occurrence of both postnecrotic fractures and cases with vital reactive changes of tissues neighbouring the fracture line.

The proposed classification may help to understand causes of periprosthetic fractures after hip resurfacing arthroplasty.