The national burden of periprosthetic hip fractures in the US: costs and risk factors for hospital readmission

Does Femoral Stem Design Influence Periprosthetic Fracture Incidence and Morphology in Total Hip Arthroplasty?

BACKGROUND

As the incidence of total hip arthroplasty (THA) increases, the number of periprosthetic femur fractures (PFF) will also rise. The surgical approach and stem design have been shown to influence the rate of PFF. This study evaluated PFF in cementless THA done through the posterior approach and described how stem design influences intraoperative and early postoperative fracture incidence and morphology.

METHODS

A retrospective review of 3,183 primary THAs for osteoarthritis from 2013 to 2021 was performed. Demographics, comorbidities, femoral stem designs, intraoperative and early postoperative PFFs (< 90 days), and aseptic femoral revisions were recorded. Stems were classified as single-wedge taper (Type 1), double-wedge taper (Type 2), or ream and broach (Type 3). There were 1,192 Type 1, 240 Type 2, and 1,726 Type 3 femoral stems. The PFF and aseptic femoral revisions were compared with univariable and multivariable analyses. Cox regression and Kaplan-Meier analyses evaluated survival to femoral revision.

RESULTS

In this population, 25 patients (0.8%) had an intraoperative or early postoperative PFF. Patients who had PFFs were older (68 versus 63; P = 0.03) and more likely to be women (76 versus 24%; P = 0.02). Type 2 stems had a significantly higher incidence of all-cause PFFs when compared to Type 1 (3.6 versus 0.7%; P < 0.01) and Type 3 (3.6 versus 0.4%; P < 0.01) stems. Type 2 stems also had a higher incidence of Vancouver B2 PFFs when compared to Type 3 stems (0.8 versus 0.05%; P = 0.04). Stem design was not associated with PFF or all-cause femoral revision. There were no differences in survival to femoral revision.

CONCLUSION

Double-wedge taper stems may be associated with increased intraoperative and early postoperative PFFs, including those requiring femoral stem revision. However, there was no statistically significant difference in late PFF, aseptic loosening, or femoral revision.

Predictors of outcomes after internal fixation of periprosthetic femoral hip fractures Subgroup analysis of the peri-implant and peri-prosthetic fractures Spanish registry (PIPPAS)

PURPOSE

To identify risk factors predisposing patients to poor outcomes after fixation of periprosthetic hip fractures around femoral stems.

METHODS

Prospective multicentre cohort study of fractures around a hip replacement stem managed by internal fixation. The primary outcome was one-year mortality, while secondary outcomes were local complications and healthcare burden-related outcomes (nursing facility utilization and hospital length of stay).

RESULTS

One-year mortality was 16.2%. Age-adjusted Charlson Comorbidity Index score (OR=1.17; 95%CI=1.03-1.33)), Pfeiffer Short Portable Mental Status Questionnaire (SPMSQ) score (OR=1.16; 1.06-1.28), prosthetic dysfunction (OR=1.90; 1.00-3.61), and postoperative medical complications (OR=1.97; 1.06-3.68) were predictors of mortality. Patients with prior prosthetic dysfunction, lower Pfeiffer SPMSQ scores, Vancouver A fractures, and fractures fixed only using cerclages were at higher risk of local complications, which occurred in 9.3% of cases. Medical (OR=1.81; 1.05-3.13) and local complications (OR=5.56; 2.42-3.13) emerged as consistent risk factors for new institutionalization. Average hospitalization time was 13.9±9.2 days. Each day of fixation delay led to an average 1.4-day increase in total hospitalization.

CONCLUSION

Frail periprosthetic hip-fracture patients with poorer functional status, dysfunctional replacements, and postoperative complications are at increased risk of mortality. Postoperative complications are more common in patients with dysfunctional arthroplasties, Vancouver A fractures, and fixation using cerclages alone. Postoperative complications were the most consistent predictor of higher healthcare resource utilization.

The CCJR® Charles A. Engh, Sr, MD. Excellence in Hip Research Award: The Evolution of Revision Hip Arthroplasty and Impact on the Trainee's Experience

BACKGROUND

Advances in total hip arthroplasty (THA) have resulted in evolving revision indications and intraoperative techniques, which can influence the exposure of trainees to complex cases. We report 3 decades of revision experience from a tertiary referral center that trains fellows, comparing the reasons for revision and the complexity of revisions over time.

METHODS

We retrospectively reviewed all revision THAs performed at our institution from 1990 to 2022. Revision diagnoses, components revised, types of revision implants used, and exposure techniques were collected. A "complex" revision was defined as a case that involved an extended trochanteric osteotomy, triflange and cup-cage construct, or acetabular augment.

RESULTS

A total of 3,556 THA revisions were identified (108 revisions/year). Aseptic loosening was the most common indication in 1990 to 1999 (45 per year), but decreased to 28.3/year in 2010 to 2019. From 1990 to 1999 and 2010 to 2019, fracture increased from 3.1 to 7.3 per year, infection from 2.9/year to 16.9/year, and metallosis from 0.1 to 13.2 per year. Both component revision were common from 1990 to 1994 (42.6 per year), while polyethylene exchange was most common in 2010 to 2019 (43.3 per year). A decrease was observed in "complex" cases over time: 14.8 extended trochanteric osteotomies/year in 2000 to 2004 compared to 5.4 per year in 2018 to 2022, 4.5 triflange and cup-cage constructs/year in 2004 to 2007 compared to 0.8 per year in 2018 to 2022, and 4 acetabular augments per year in 2009 to 2012 compared to 1 per year in 2018 to 2022.

CONCLUSIONS

Indications for revision have changed over the decades, while the number of "complex" revisions has gradually decreased, presumably due to advances in implants and materials. If this trend extends to other training institutions, the next generation of arthroplasty surgeons will have less exposure to complex revisions during their training.

Outcomes Following Intraoperative Calcar Fractures During Cementless Total Hip Arthroplasty

BACKGROUND

Intraoperative calcar fractures (IOCFs) are an established complication of cementless total hip arthroplasty (THA). Prompt recognition and management may prevent subsequent postoperative complications. This study aimed to evaluate the outcomes and revision rates of THAs with IOCFs identified and managed intraoperatively.

METHODS

There were 11,438 primary cementless THAs performed at a single institution from 2009 to 2022. Prospectively collected data on cases with an IOCF was compared to cases without the complication. The fracture group had a lower body mass index (26.9 versus 28.9 kg/m2; P = .01). Patient age, sex, and mean follow-up (3.2 (0 to 12.8) versus 3.5 years (0 to 14); P = .45) were similar between groups.

RESULTS

An IOCF occurred in 62 of 11,438 (0.54%) cases. The THAs done via a direct anterior approach experienced the lowest rate of fractures (31 of 7,505, 0.4%) compared to postero-lateral (27 of 3,759, 0.7%; P = .03) and lateral (4 of 165, 2.4%; P < .01) approaches. Of the IOCFs, 48 of 62 (77%) were managed with cerclage cabling, 4 of 62 (6.5%) with intraoperative stem design change and cabling, 4 of 62 (6.5%) with restricted weight-bearing, and 6 of 62 (9.7%) with no modification to the standard postoperative protocol. The IOCF group experienced one case of postoperative component subsidence. No subjects in the IOCF cohort required revision, and rates were similar between groups (0 of 62, 0% versus 215 of 11,376, 1.9%; P = .63). Postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement scores were comparable (85.7 versus 86.4; P = .80).

CONCLUSIONS

Cementless THA complicated by IOCF had similar postoperative revision rates and patient-reported outcome measures at early follow-up when compared to patients not experiencing this complication. Surgeons may use these data to provide postoperative counseling on expectations and outcomes following these rare intraoperative events.

Incidence and risk factors of postoperative delirium following hepatic resection: a retrospective national inpatient sample database study

BACKGROUND

Postoperative delirium (POD) is a common complication after major surgery and can cause a variety of adverse effects. However, no large-scale national database was used to assess the occurrence and factors associated with postoperative delirium (POD) following hepatic resection.

METHODS

Patients who underwent hepatic resection from 2015 to 2019 were screened using the International Classification of Diseases (ICD) 10th edition clinical modification code from the National Inpatient Sample (NIS) Database. Peri-operative factors associated with delirium were screened and underwent statistical analysis to identify independent predictors for delirium following hepatic resection.

RESULTS

A total of 80,070 patients underwent hepatic resection over a five-year period from 2015 to 2019. The overall occurrence of POD after hepatic resection was 1.46% (1039 cases), with a slight upward trend every year. The incidence of elective admission was 6.66% lower (88.60% vs. 81.94%) than that of patients without POD after hepatic resection and 2.34% (45.53% vs. 43.19%) higher than that of patients without POD in teaching hospitals (P < 0.001). In addition, POD patients were 6 years older (67 vs. 61 years) and comprised 9.27% (56.69% vs. 47.42%) more male patients (P < 0.001) compared to the unaffected population. In addition, the occurrence of POD was associated with longer hospitalization duration (13 vs. 5 days; P < 0.001), higher total cost ($1,481,89 vs. $683,90; P < 0.001), and higher in-hospital mortality (12.61% vs. 4.11%; P < 0.001). Multivariate logistic regression identified hepatic resection-independent risk factors for POD, including non-elective hospital admission, teaching hospital, older age, male sex, depression, fluid and electrolyte disorders, coagulopathy, other neurological disorders, psychoses, and weight loss. In addition, the POD after hepatic resection has been associated with sepsis, dementia, urinary retention, gastrointestinal complications, acute renal failure, pneumonia, continuous invasive mechanical ventilation, blood transfusion, respiratory failure, and wound dehiscence / non-healing.

CONCLUSION

Although the occurrence of POD after hepatic resection is relatively low, it is beneficial to investigate factors predisposing to POD to allow optimal care management and improve the outcomes of this patient population.

Comparison of patient demographics and patient-specific risk factors for readmissions following open reduction and internal fixation for acetabular fractures

PURPOSE

Acetabular fractures are highly complex injuries often resulting from high-energy trauma. The gold standard treatment for these injuries has become open reduction internal fixation (ORIF). The purpose of this study is to further this understanding and investigate how (1) patient demographics and (2) patient-specific risk factors affect 90-day readmission rates.

METHODS

A retrospective, nationwide query of private insurance database from January 1st, 2010 to October 31st, 2020 was performed using ICD-9, ICD-10, and CPT codes. Patients who underwent acetabular ORIF and were readmitted within 90 days following index procedure were included, patients who were not readmitted served as controls. Patients were divided by demographics and specific risk factors associated with readmission.

RESULTS

The query yielded a total of 3942 patients. Age and sex were found to be non-significant contributing risk factors to 90-day readmissions. Data also showed that statistically significant comorbidities included arrhythmia, cerebrovascular disease, coagulopathy, fluid and electrolyte abnormalities, and pathologic weight loss.

CONCLUSION

This study illustrated how several patient-specific risk factors may contribute to increased 90-day readmission risk following acetabular ORIF. A heightened awareness of these comorbidities in patients requiring acetabular ORIF is required to improve patient outcomes and minimize rates of readmission. Further investigation is needed to improve patient outcomes, and increase awareness of potential post-operative complications in these higher-risk patient populations.

Health status after periprosthetic proximal femoral fractures

Aims

Periprosthetic proximal femoral fractures (PFFs) are a major complication after total hip arthroplasty (THA). Health status after PFF is not specifically investigated. The aim of this study is to evaluate the health status pattern over two years after sustaining a PFF.

Methods

A cohort of patients with PFF after THA was derived from the Brabant Injury Outcomes Surveillance (BIOS) study. The BIOS study, a prospective, observational, multicentre follow-up cohort study, was conducted to obtain data by questionnaires pre-injury and at one week, and one, three, six, 12, and 24 months after trauma. Primary outcome measures were the EuroQol five-dimension three-level questionnaire (EQ-5D-3L), the Health Utility Index 2 (HUI2), and the Health Utility Index 3 (HUI3). Secondary outcome measures were general measurements such as duration of hospital stay and mortality.

Results

A total of 70 patients with a PFF were included. EQ-5D utility scores were significantly lower on all timepoints except at six months' follow-up compared to pre-injury. EuroQol visual analogue scale (EQ-VAS) scores at one month's follow-up were significantly lower compared to pre-injury. The percentage of reported problems at two years was higher for all dimensions except anxiety/depression when compared to pre-injury. The mean EQ-5D utility score was 0.26 higher in males compared to females (95% confidence interval (CI) 0.01 to 0.42; p = 0.003). The mean EQ-VAS score for males was 8.9 points higher when compared to females over all timepoints (95% CI 1.2 to 16.7; p = 0.027). Mortality was 10% after two years' follow-up.

Conclusion

PFF patients are a frail population with substantial functional impairment at baseline. Post-injury, they have a significant and clinically relevant lower health status two years after trauma when compared to pre-injury. Health status improves the most between one and three months after injury. Two years after PFF, more patients experience problems in mobility, self-care, usual activities, and pain/discomfort than pre-injury.

What Are the Mortality, Infection, and Nonunion Rates After Periprosthetic Femoral Fractures in the United States?

BACKGROUND

Periprosthetic femoral fractures are a serious complication that put a high burden on patients. However, comprehensive analyses of their incidence, mortality, and complication rates based on large-registry data are scarce.

QUESTIONS/PURPOSES

In this large-database study, we asked: (1) What is the incidence of periprosthetic femoral fractures in patients 65 years and older in the United States? (2) What are the rates of mortality, infection, and nonunion, and what factors are associated with these outcomes?

METHODS

In this retrospective, comparative, large-database study, periprosthetic femoral fractures occurring between January 1, 2010, and December 31, 2019, were identified from Medicare physician service records encompassing services rendered in medical offices, clinics, hospitals, emergency departments, skilled nursing facilities, and other healthcare institutions from approximately 2.5 million enrollees. These were grouped into proximal, distal, and shaft fractures after TKA and THA. We calculated the incidence of periprosthetic femur fractures by year. Incidence rate ratios (IRR) were calculated by dividing the incidence in 2019 by the incidence in 2010. The Kaplan-Meier method with Fine and Gray subdistribution adaptation was used to calculate the cumulative incidence rates of mortality, infection, and nonunion. Semiparametric Cox regression was applied with 23 measures as covariates to determine factors associated with these outcomes.

RESULTS

From 2010 to 2019, the incidence of periprosthetic femoral fractures increased steeply (TKA for distal fractures: IRR 3.3 [95% CI 1 to 9]; p = 0.02; THA for proximal fractures: IRR 2.3 [95% CI 1 to 4]; p = 0.01). One-year mortality rates were 23% (95% CI 18% to 28%) for distal fractures treated with THA, 21% (95% CI 19% to 24%) for proximal fractures treated with THA, 22% (95% CI 19% to 26%) for shaft fractures treated with THA, 21% (95% CI 18% to 25%) for distal fractures treated with TKA , 22% (95% CI 17% to 28%) for proximal fractures treated with TKA, and 24% (95% CI 19% to 29%) for shaft fractures treated with TKA. The 5-year mortality rate was 63% (95% CI 54% to 70%) for distal fractures treated with THA, 57% (95% CI 54% to 62%) for proximal fractures treated with THA, 58% (95% CI 52% to 63%) for shaft fractures treated with THA, 57% (95% CI 52% to 62%) for distal fractures treated with TKA , 57% (95% CI 49% to 65%) for proximal fractures treated with TKA, and 57% (95% CI 49% to 64%) for shaft fractures treated with TKA. Age older than 75 years, male sex, chronic obstructive pulmonary disease (HR 1.48 [95% CI 1.32 to 1.67] after THA and HR 1.45 [95% CI 1.20 to 1.74] after TKA), cerebrovascular disease after THA, chronic kidney disease (HR 1.28 [95% CI 1.12 to 1.46] after THA and HR 1.50 [95% CI 1.24 to 1.82] after TKA), diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis were clinical risk factors for an increased risk of mortality. Within the first 2 years, fracture-related infections occurred in 5% (95% CI 4% to 7%) of patients who had distal fractures treated with THA, 5% [95% CI 5% to 6%]) of patients who had proximal fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had shaft fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had distal fractures treated with TKA , 7% (95% CI 5% to 9%) of patients who had proximal fractures treated with TKA, and 6% (95% CI 4% to 8%) of patients who had shaft fractures treated with TKA. Nonunion or malunion occurred in 3% (95% CI 2% to 4%) of patients with distal fractures treated with THA, 1% (95% CI 1% to 2%) of patients who had proximal fractures treated with THA, 2% (95% CI 1% to 3%) of patients who had shaft fractures treated with THA, 4% (95% CI 3% to 5%) of those who had distal fractures treated with TKA, , 2% (95% CI 1% to 4%) of those who had proximal fractures treated with TKA, and 3% (95% CI 2% to 4%) of those who had shaft fractures treated with TKA.

CONCLUSION

An increasing number of periprosthetic fractures were observed during the investigated period. At 1 and 5 years after periprosthetic femur fracture, there was a substantial death rate in patients with Medicare. Conditions including cerebrovascular illness, chronic kidney disease, diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis are among the risk factors for increased mortality. After the surgical care of periprosthetic femur fractures, the rates of fracture-related infection and nonunion were high, resulting in a serious risk to affected patients. Patient well-being can be enhanced by an interdisciplinary team in geriatric traumatology and should be improved to lower the risk of postoperative death. Additionally, it is important to ensure that surgical measures to prevent fracture-related infections are followed diligently. Furthermore, there is a need to continue improving implants and surgical techniques to avoid often-fatal complications such as fracture-associated infections and nonunion, which should be addressed in further studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Are periprosthetic hip fractures more severe than native hip fractures? A systematic review of outcomes and resource utilization

BACKGROUND

There is a paucity of data comparing periprosthetic hip fracture (PPHFx) outcomes and resource utilization to native fractures. Many surgeons consider periprosthetic hip fractures to be more severe injuries than native fractures. The aim of this systematic review is to characterize the outcomes of PPHFx and assess their severity relative to native hip fractures (NHFx).

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analysis systematic review was conducted using Medline, Biosis, and Cinahl. Primary outcomes were time to surgery, length of stay (LOS), cost of management, disposition, complication rates, readmission rates, and mortality.

RESULTS

14 articles (13,489 patients) from 2010 to 2018 were included in the study. Study quality was generally low. Patient follow-up ranged from 1 month to 3.2 years. LOS ranged from 5.2 to 38 days. US cost of management was best estimated at $53,669 ± 19,817. Discharge to skilled nursing facilities ranged from 64.5 to 74.5%. Time to surgery ranged from 1.9 to 5.7 days. Readmission rates ranged from 12 to 32%. Per Clavien-Dindo classification, 33.9% suffered minor complications; 14.3% suffered major complications. 1 month and 1 year mortality ranged from 2.9% to 10% and 9.7% to 45%, respectively.

CONCLUSION

Time to surgery and LOS were longer for PPHFx relative to NHFx. Complications' rates were higher for PPHFx compared to NHFx. There is no evidence for differences in LOS, cost, discharge, readmission rates, or mortality between PPHFx and NHFx. These results may serve as a baseline in future evaluation of PPHFx management.

Incidence and risk factors of in-hospital prosthesis-related complications following total shoulder arthroplasty

BACKGROUND

The occurrence of prosthesis-related complications after total shoulder arthroplasty is devastating and costly. The purpose was to determine the incidence and risk of in-hospital prosthesis-related complications after total shoulder arthroplasty utilizing a large-scale sample database.

METHODS

A retrospective database analysis was performed based on Nationwide Inpatient Sample from 2010 to 2014. Patients who underwent total shoulder arthroplasty were included. Patient demographics, hospital characteristics, length of stay, economic indicators, in-hospital mortality, comorbidities, and peri-operative complications were evaluated.

RESULTS

A total of 34,198 cases were capture from the Nationwide Inpatient Sample database. There were 343 cases of in-hospital prosthesis-related complications after total shoulder arthroplasty and the overall incidence was 1%, with a more than 2.5-fold decrease from 2010 to 2014. Dislocation was the most common category among prosthesis-related complications (0.1%). The occurrence of in-hospital prosthesis-related complications was associated with significantly more total charges and slightly longer length of stay while less usage of Medicare. Risk factors of prosthesis-related complications were identified including younger age (<64 years), female, the native American, hospital in the South, alcohol abuse, depression, uncomplicated diabetes, diabetes with chronic complications, fluid and electrolyte disorders, metastatic cancer, neurological disorders, and renal failure. Interestingly, advanced age (≥65 years) and proprietary hospital were found as protective factors. Furthermore, prosthesis-related complications were associated with aseptic necrosis, rheumatoid arthritis, rotator cuff tear arthropathy, Parkinson's disease, prior shoulder arthroscopy, and blood transfusion.

CONCLUSIONS

It is of benefit to study risk factors of prosthesis-related complications following total shoulder arthroplasty to ensure the appropriate management and optimize consequences although a relatively low incidence was identified.

Penalty for Switching Implants? Assessing the Learning Curve With a Collarless, Tapered Wedge Cementless Femoral Component

Background

Surgeon learning curve associated with a tapered wedge femoral implant as measured by early femoral component subsidence and 90-day risk of reoperation was evaluated.

Methods

The first 451 patients undergoing primary, cementless total hip arthroplasty by a single, fellowship-trained arthroplasty surgeon with a tapered wedge stem design were retrospectively reviewed. Early radiographic femoral component subsidence during the first 6 weeks postoperatively and 90-day reoperations was recorded.

Results

When stratified by approach, there was no association between date of surgery and femoral component subsidence in the posterior approach (P-value for linear trend over time = 0.44). In the direct anterior approach, there was a significant association between date of surgery and early femoral component subsidence (P-value for linear trend over time = 0.01). For both approaches, there was an increase in implanted stem size relative to templated stem size over time (P < .01 and P = .03, respectively). There was no association between the date of surgery and risk of 90-day reoperation (P = .45).

Conclusions

In a single surgeon's initial use of a tapered cementless wedge stem, early femoral component subsidence was not impacted by the surgeon's learning curve when the posterior approach was utilized. Although subsidence was associated with date of surgery in the direct anterior cohort, this was not associated with increased risk of 90-day reoperation. Should a surgeon adopt a new tapered-wedge stem, these findings suggest that the stem is forgiving both in relation to subsidence and 90-day reoperation risk when appropriate surgical technique is utilized.

CT required to perform robotic-assisted total hip arthroplasty can identify previously undiagnosed osteoporosis and guide femoral fixation strategy

Osteoporosis can determine surgical strategy for total hip arthroplasty (THA), and perioperative fracture risk. The aims of this study were to use hip CT to measure femoral bone mineral density (BMD) using CT X-ray absorptiometry (CTXA), determine if systematic evaluation of preoperative femoral BMD with CTXA would improve identification of osteopenia and osteoporosis compared with available preoperative dual-energy X-ray absorptiometry (DXA) analysis, and determine if improved recognition of low BMD would affect the use of cemented stem fixation. Retrospective chart review of a single-surgeon database identified 78 patients with CTXA performed prior to robotic-assisted THA (raTHA) (Group 1). Group 1 was age- and sex-matched to 78 raTHAs that had a preoperative hip CT but did not have CTXA analysis (Group 2). Clinical demographics, femoral fixation method, CTXA, and DXA data were recorded. Demographic data were similar for both groups. Preoperative femoral BMD was available for 100% of Group 1 patients (CTXA) and 43.6% of Group 2 patients (DXA). CTXA analysis for all Group 1 patients preoperatively identified 13 osteopenic and eight osteoporotic patients for whom there were no available preoperative DXA data. Cemented stem fixation was used with higher frequency in Group 1 versus Group 2 (28.2% vs 14.3%, respectively; p = 0.030), and in all cases where osteoporosis was diagnosed, irrespective of technique (DXA or CTXA). Preoperative hip CT scans which are routinely obtained prior to raTHA can determine bone health, and thus guide femoral fixation strategy. Systematic preoperative evaluation with CTXA resulted in increased recognition of osteopenia and osteoporosis, and contributed to increased use of cemented femoral fixation compared with routine clinical care; in this small study, however, it did not impact short-term periprosthetic fracture risk.

A cost analysis of treating postoperative periprosthetic femoral fractures following hip replacement surgery in a UK tertiary referral centre

AIM

This study aims to evaluate costs associated with periprosthetic femoral fracture (PFF) treatment at a UK tertiary referral centre.

METHODS

This study included 128 consecutive PFFs admitted from 02/04/2014-19/05/2020. Financial data were provided by Patient Level Information and Costing Systems. Primary outcomes were median cost and margin. Secondary outcomes were length of stay, blood transfusion, critical care, 30-day readmission, 2-year local complication, 2-year systemic complication, 2-year reoperation and 30-day mortality rates. Statistical comparisons were made between treatment type. Statistical significance was set at p<0.05.

RESULTS

Across the cohort, median cost was £15,644.00 (IQR £11,031.00-£22,255.00) and median loss was £3757.50 (£599.20-£8296.20). The highest costs were ward stay (£3994.00, IQR £1,765.00-£7,013.00), theatre utilisation (£2962.00, IQR £0.00-£4,286.00) and overheads (£1705.10, IQR £896.70-£2432.20). Cost (£17,455.00 [IQR, £13,194.00-£23,308.00] versus £7697.00 [IQR £3871.00-£10,847.00], p<0.001) and loss (£4890.00 [IQR £1308.00-£10,009.00] versus £1882.00 [IQR £313.00-£3851.00], p = 0.02) were greater in the operative versus the nonoperative group. There was no difference in cost (£17,634.00 [IQR £12,965.00-£22,958.00] versus £17,399.00 [IQR £13,394.00-£23,404.00], p = 0.98) or loss (£5374.00 [IQR £1950.00-£10,143.00] versus £3860.00 [IQR -£95.50-£7601.00], p = 0.21) between the open reduction and internal fixation (ORIF) and revision groups. More patients required blood transfusion in the operative versus the nonoperative group (17 [17.9%] versus 0 [0.0%], p = 0.009). There was no difference in any clinical outcome between the ORIF and revision groups (p>0.05).

CONCLUSION

PFF treatment costs are high with inadequate reimbursement from NHS tariff. Work is needed to address this disparity and reduce hospital costs. Cost should not be used to decide between ORIF and revision surgery.

[Treatment of periprosthetic fractures in Europe during the pandemic]

OBJECTIVE

To study the impact of reorganization of European hospitals during the most severe phase of the SARS-CoV-2 pandemic on standards of care and early outcomes in patients with periprosthetic fractures.

MATERIAL AND METHODS

We reviewed available data collected from 14 hospitals in Northern Italy during the quarantine period between March 9 and May 4, 2020. The study included all patients admitted to emergency departments with periprosthetic fractures and scheduled for surgery within a 2-month period. Periprosthetic fractures were classified according to the Uniform Classification System (UCS). Distribution normality was tested using the Kolmogorov-Smirnov test. Accordingly, data were described as non-parametric. Statistical analysis was performed using the Microsoft Excel v. 16.0.

RESULTS

In total, 1390 patients admitted to the Department of Orthopedics and Traumatology for emergency care throughout the follow-up period including 38 (2.7%) ones with periprosthetic fractures. There were 12 (31.5%) men and 26 (68.5%) women. Mean age was 81 years (range 70-96). Screening for SARS-CoV-2 by swab was performed in 23 out of 38 patients (60.5%) at admission. It was positive in 2 (5.3%) cases. Three out of thirty-eight patients (7.9%) were diagnosed with COVID-19 due to clinical signs. Of these, 2 patients were diagnosed with COVID-19 before surgery, 3 patients - after surgery. Although the study period coincided with quarantine, the number of admissions for periprosthetic fractures (3%) was similar to that in 2019 and accounted for 3% of the total number of visits to the traumatology and orthopedics departments.

CONCLUSION

The study revealed no obvious changes in hospitalizations for periprosthetic fractures despite social restrictions during the first wave of the COVID-19 pandemic. In emergency, hospitals were still able to provide standard care for patients with periprosthetic fractures despite significant amount of resources redirected for the pandemic.

Uncemented Collared Femoral Stems in Total Hip Arthroplasty

The procedure of total hip arthroplasty (THA) is rapidly evolving. Patients undergoing THA are younger and more active, and they demand an earlier return to their daily activities. All of these factors increase both the early forces on uncemented femoral stems and the risk for complications. Consequently, surgeons must choose implants that provide immediate primary stability. This has led to renewed interest in the use of uncemented collared stems, which have benefits including increased primary stability, decreased risk of subsidence and periprosthetic fracture, and improved load transfer to the proximal femur. [Orthopedics. 2022;45(3):e122-e126.].

Short single-wedge stems have higher risk of periprosthetic fracture than other cementless stem designs in Dorr type A femurs: a finite element analysis

BACKGROUND

The use of total hip arthroplasty (THA) femoral stems that transmit force in a favourable manner to the femur may minimise periprosthetic fractures. Finite element analysis (FEA) is a computerised method that analyses the effect of forces applied to a structure with complex shape. Our aim was to apply FEA to compare primary THA cementless stem designs and their association with periprosthetic fracture risk.

METHODS

3-dimensional (3D) models of a Dorr Type A femur and 5 commonly used primary THA cementless stem designs (short single wedge, standard-length single wedge, modular, double-wedge metaphyseal filling, and cylindrical fully coated) were developed using computed tomography (CT) imaging. Implant insertion, single-leg stance, and twisting with a planted foot were simulated. FEA was performed, and maximum femoral strain along the implant-bone interface recorded.

RESULTS

Femoral strain was highest with short single-wedge stem design (0.3850) and lowest with standard-length single-wedge design (0.0520). Location of maximum femoral strain varied by stem design, but not with implant insertion, single-leg stance, or twisting with a planted foot. Strain was as high during implant insertion as with single-leg stance or twisting with a planted foot.

CONCLUSIONS

Our results suggest the risk of intraoperative and postoperative periprosthetic fracture with THA in a Dorr A femur is highest with short single-wedge stems and lowest with standard-length single-wedge stems. Consideration may be given to minimising the use of short single-wedge stems in THA. Implant-specific sites of highest strain should be carefully inspected for fracture.

Mortality After Postoperative Periprosthetic Fracture of the Femur After Hip Arthroplasty in the Last Decade: Meta-Analysis of 35 Cohort Studies Including 4841 Patients

BACKGROUND

Postoperative periprosthetic fracture of the femur (POPFF) is associated with increased mortality. There is a lack of general estimates of mortality after POPFF and a need for higher-level evidence in this area. The aim of this study was to estimate mortality after POPFF using data reported in cohort studies from the last decade.

METHODS

Literature search was conducted using Medline and Embase. The primary outcome was all-cause mortality during time as an inpatient, within 30 days, within 90 days, and within one year of POPFF. Mortality (95% confidence interval [CI]) was estimated using metaregression.

RESULTS

A total of 4841 patients from 35 cohort studies were included. Study quality was generally low. The weighted mean follow-up was 2.3 years, and the most common POPFF was Vancouver B. The pooled mortality as an inpatient was 2.4% (95% CI 1.6% to 3.4%). The pooled mortality within 30 days was 3.3% (95% CI 2.0% to 5.0%). The pooled mortality within 90 days was 4.8% (95% CI 3.6% to 6.1%). The pooled mortality within one year was 13.4% (95% CI 11.9% to 14.8%). Mortality after POPFF was like that of neck of femur fracture up to 30 days, but better at one year.

CONCLUSION

Mortality is like that experienced by patients after neck of femur fracture up to 30 days, but better at one year, which may represent the lower underlying risk of death in the POPFF cohort. These results may form the basis for evaluation of services treating POPFF in the future.

Long-term results of metal-on-metal hip resurfacing in patients 65 years of age or older

BACKGROUND

Metal-on-metal hip resurfacing arthroplasty (MMHRA) is typically used in young and active patients because they have the most to gain from this bone-preserving procedure. However, there is very little long-term data on the performance of MMHRA in patients 65 years of age or older because of the efficacy of conventional total hip arthroplasty in this patient population.

METHODS

109 patients (124 hips) age ⩾65 years were treated with Conserve Plus MMHRA. There were 83 male and 26 female patients. Their mean age at surgery was 69.5 (range 65-83) years. UCLA hip scores, SF-12 quality of life score were collected at follow-up visits. Radiographic and survivorship analyses were performed.

RESULTS

SF-12 scores and UCLA scores were maintained over time except for a small decrease in activity. 4 patients underwent revision surgery. The 15-year Kaplan-Meier survivorship of the cohort was 93.7%. All revisions surgeries were successful at a mean follow-up time of 113 (range 30-218) months. Unusual radiographic findings from our previous publication did not progress over time except for 1 hip that showed a complete radiolucency around the acetabular component.

CONCLUSIONS

Our results clearly show that HRA is a viable prosthetic solution with many advantages for all active patients, regardless of their age at the time of surgery.

Outcomes of Vancouver C Periprosthetic Femur Fractures

BACKGROUND

Periprosthetic femur fractures (PFFs) that occur distal to a total hip arthroplasty, Vancouver C fractures, are challenging to treat. We aimed to report patient mortality, reoperations, and complications following Vancouver C PFFs in a contemporary cohort all treated with a laterally based locking plate.

METHODS

We retrospectively identified 42 consecutive Vancouver C PFFs between 2004 and 2018. There was a high prevalence of comorbidities, including 9 patients with neurologic conditions, 9 with a history of cancer, 8 diabetics, and 8 using chronic anticoagulation. Mean time from total hip arthroplasty to PFF was 6 years (range 1 month to 25 years). All fractures were treated with a laterally based locking plate. Fixation bypassed the femoral component in 98% of cases and extended as proximal as the lesser trochanter in 18%. Kaplan-Meier survival was used for patient mortality, and a competing risk model was used to analyze survivorship free of reoperation and nonunion. Mean follow-up was 2 years.

RESULTS

Patient mortality was 5% at 90 days and 31% at 2 years. Cumulative incidence of reoperation was 13% at 2 years. There were 5 reoperations including revision osteosynthesis for nonunion and/or hardware failure (2), debridement and hardware removal for infection (2), and removal of hardware and total knee arthroplasty for post-traumatic arthritis (1). Cumulative incidence of nonunion was 10% at 2 years.

CONCLUSION

Patients who sustained a Vancouver C PFFs had a high mortality rate (31%) at 2 years. Moreover, 13% of patients required a reoperation within 2 years, most commonly for infection or nonunion.

The cost-effectiveness of outpatient surgery for primary total hip arthroplasty in the United States: a computer-based cost-utility study

PURPOSE

The purpose of this study was to perform a cost-effectiveness analysis of outpatient versus inpatient total hip arthroplasty (THA) in the USA, considering complication probability and the potential cost of such complications.

METHODS

A cost-effectiveness analysis was conducted from the societal perspective to evaluate the incremental cost and effectiveness of inpatient THA compared to outpatient THA over a lifetime horizon. Effectiveness was expressed in quality-adjusted life years (QALYs). Costs, expressed in 2019 US dollars, transition probabilities, and health utilities were derived from the literature. The primary outcome was the incremental cost-effectiveness ratio (ICER), with a willingness to pay (WTP) threshold set at $50,000/QALY. 1-way and probabilistic sensitivity analyses was performed to evaluate the effect of the various variables on the model.

RESULTS

In the base case, inpatient THA was more effective in terms of total utility (10.36 vs. 10.30 QALY), but also more costly ($48,155 ± 1673 vs. $43,288 ± 1, 606 for Medicare) than outpatient THA. Even with a lifetime horizon, the ICER was $81,116 per QALY and $140,917 per QALY for Medicare and private payer insurance, respectively, which is higher than the willingness to pay threshold. 1-way sensitivity analyses indicated that the variables having the most influence on the model were the utility of inpatient and outpatient THA and cost of inpatient and outpatient THA.

CONCLUSIONS

This model determined that for a WTP threshold set at $50,000/QALY, outpatient THA is more cost-effective than inpatient THA from a societal perspective. Despite this, surgeons must weigh clinical factors first and foremost in determining if an individual patient can be safely operated on in the outpatient setting.

Periprosthetic Hip Fractures With a Loose Stem: Open Reduction and Internal Fixation Versus Stem Revision

BACKGROUND

It is recommended revision for periprosthetic hip fractures (PPHF) with a loose stem. However, several authors have argued that under certain conditions, this fracture could be treated using osteosynthesis. The aim is to compare stem revision versus internal fixation in the treatment of PPHF with a loose stem.

METHODS

All patients with PPHF with a loose stem treated by osteosynthesis and stem revision between January 2009 and January 2019 were included. We assessed hospital stay, American Society of Anesthesiologists, Charlson comorbidity index, surgery time, blood transfusion, complications, reoperation rate, first-year mortality, radiological, and functional results.

RESULTS

A total of 57 patients were included (40 osteosyntheses and 17 stem revision), with an average follow-up time of 3.1 years. Their mean age was 78.47 years (R 45-92). In the osteosynthesis group, fewer patients required blood transfusion (32.5% vs. 70.6%), surgical times were shorter (108 minutes vs. 169 minutes), and the cost was lower, both in terms of total cost (€14,239.07 vs. €21,498.45 and operating room cost (€5014.63 vs. €8203.34). No significant differences were found between the groups in terms of complications, reoperation rate, or functional outcomes.

CONCLUSION

Compared with stem revision, osteosynthesis requires less surgery time, has a lower need for blood transfusions, and a reduced hospital cost. Stem revision remains the treatment of choice in PPHF with a loose stem, but in V-B2 fractures in elderly patients with low functional demand, high anesthetic risk (American Society of Anesthesiologists ≥3), and many comorbidities (Charlson comorbidity index ≥5) in whom anatomic reconstruction is possible, osteosynthesis can be a viable option.

EVIDENCE LEVEL

Historical cohorts. Level III.

Selected Vancouver B2 periprosthetic femoral fractures around cemented polished femoral components can be safely treated with osteosynthesis

AIMS

We aimed to compare the implant survival, complications, readmissions, and mortality of Vancouver B2 periprosthetic femoral fractures (PFFs) treated with internal fixation with that of B1 PFFs treated with internal fixation and B2 fractures treated with revision arthroplasty.

METHODS

We retrospectively reviewed the data of 112 PFFs, of which 47 (42%) B1 and 27 (24%) B2 PFFs were treated with internal fixation, whereas 38 (34%) B2 fractures underwent revision arthroplasty. Decision to perform internal fixation for B2 PFFs was based on specific radiological (polished femoral components, intact bone-cement interface) and clinical criteria (low-demand patient). Median follow-up was 36.4 months (24 to 60). Implant survival and mortality over time were estimated with the Kaplan-Meier method. Adverse events (measured with a modified Dindo-Clavien classification) and 90-day readmissions were additionally compared between groups.

RESULTS

In all, nine (8.01%) surgical failures were detected. All failures occurred within the first 24 months following surgery. The 24-month implant survival was 95.4% (95% confidence interval (CI) 89.13 to 100) for B1 fractures treated with internal fixation, 90% (95% CI 76.86 to 100) for B2 PFFs treated with osteosynthesis-only, and 85.8% (95% CI 74.24 to 97.36) for B2 fractures treated with revision THA, without significant differences between groups (p = 0.296). Readmissions and major adverse events including mortality were overall high, but similar between groups (p > 0.05). The two-year patient survival rate was 87.1% (95% CI 77.49 to 95.76), 66.7% (95% CI 48.86 to 84.53), and 84.2% (95% CI 72.63 to 95.76), for the B1 group, B2 osteosynthesis group, and B2 revision group, respectively (p = 0.102).

CONCLUSION

Implant survival in Vancouver B2 PFFs treated with internal fixation was similar to that of B1 fractures treated with the same method and to B2 PFFs treated with revision arthroplasty. Low-demand, elderly patients with B2 fractures around well-cemented polished femoral components with an intact bone-cement interface can be safely treated with internal fixation. Cite this article: Bone Joint J 2021;103-B(7):1222-1230.

Periprosthetic Femur Fractures After Total Hip Arthroplasty: Does the Mode of Failure Correlate With Classification?

BACKGROUND

Periprosthetic femur fracture is one of the most common indications for reoperation after total hip arthroplasty. Our objectives were to evaluate the incidence of reoperation after the surgical treatment of periprosthetic femur fractures and to compare the mechanisms of failure between fractures around a stable femoral component and those with an unstable femoral component.

METHODS

We identified a consecutive series of 196 surgically treated periprosthetic fractures after total hip arthroplasty between 2008 and 2017. Mean age was 72 years (range, 29-96 years), and 108 (55%) were women. The femoral component was unstable in 127 cases (65%) and stable in the remaining 69 cases (35%). Mean follow-up was 2 years.

RESULTS

The 2-year cumulative probability of any reoperation was 19%. The most common indication for reoperation among the cases with a stable femoral component was nonunion, and the most common indication for reoperation among the cases with an unstable femoral component was infection. Fractures that originated at the distal aspect of the femoral component were associated with a high risk of nonunion (6 of 28 cases, P < .01) and reoperation (9 of 28 cases, P = .03).

CONCLUSION

Surgeons should take measures to mitigate the failure modes that are distinct based on fracture type. The high infection rate after surgical management of B₂ fracture suggests that additional antiseptic precautions may be warranted. For B₁ fractures, particularly those originating near the distal aspect of the femoral component, augmenting fixation with orthogonal plating, spanning the entire femur, or revising the stem in cases of poor proximal bone should be considered.

Periprosthetic Femur Fracture Risk: Influenced by Stem Choice, Not Surgical Approach

BACKGROUND

Periprosthetic femur fracture (PFF) remains a common reason for failure after total hip arthroplasty (THA). For over 10 years, our institution has performed both anterior approach (AA) and posterolateral (PL) approaches for primary THA with multiple stem designs. The aim of this study is to determine the 90-day relative risk of PFF with regard to approach and stem design.

METHODS

A retrospective review of our institutional database was performed on all patients undergoing primary THA from 2007 to 2018 using AA or PL approaches. Five surgeons performing 6309 THAs (AA = 4510; PL = 1799) using single-wedge taper (n = 2417) or fit-and-fill (n = 3892) stems were included. PFF occurring within 90 days of the index procedure were analyzed. Differences in PFF rates, fracture location, stem type, and treatment method were assessed. Comparisons were made using a Cox regression analysis.

RESULTS

The 90-day revision rate for fracture was 0.3%. Clinically significant fractures requiring cerclage cabling, stem change, revision, or open reduction internal fixation occurred in 0.9% of patients (intraoperative = 37, 0.6%; postoperative = 17, 0.3%). Cox regression found PFF risk was significant for female patients (P = .008), patients older than age 65 (P < .01), single-wedge taper stems (P = .05), and for cases with collarless stems (P = .04). Among PFF cases that required surgical intervention, risk factors were female sex, age older than 65, and body mass index under 25 (P < .05). Collarless stems were 2.6 times more likely to result in PFF than collared stems (P = .04). Single-wedge taper stems were 2.3 times more likely to result in PFF than fit-and-fill stems (P = .05). Approach was not found to be an independent risk factor for PFF (P = .85).

CONCLUSION

Our single-center experience demonstrates the risk of periprosthetic fracture within 90 days of surgery is significantly lower with collared stems and fit-and-fill stem designs. Female sex, age over 65, and body mass index below 25 nearly double the PFF risk. Surgical approach did not influence fracture rates.

The "Double Washer" Technique Is an Effective Strategy for Bicortical Fixation in Periprosthetic Fractures About a Femoral Stem: A Technical Trick and Case Series

Periprosthetic fractures about the hip and knee are challenging injuries to treat for the orthopaedic surgeon. The pre-existing femoral implant and poor bone quality provide for difficulties in achieving stable fixation. We present a surgical technique and clinical series of 5 patients describing the use and outcomes of a 3.5 screw with a "double washer" technique to achieve bicortical fixation around a femoral prosthesis.

Do standards of care and early outcomes of periprosthetic fractures change during the COVID-19 pandemic? A multicentre study

BACKGROUND

Periprosthetic fractures (PPFs) are a growing matter for orthopaedic surgeons, and patients with PPFs may represent a frail target in the case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The purpose of this study is to investigate whether hospital reorganisations during the most severe phase of the SARS-CoV-2 pandemic affected standards of care and early outcomes of patients treated for PPFs in Northern Italy.

MATERIALS AND METHODS

Data were retrieved from a multicentre retrospective orthopaedics and traumatology database, including 14 hospitals. The following parameters were studied: demographics, results of nasopharyngeal swabs, prevalence of coronavirus disease 2019 (COVID-19), comorbidities, general health status (EQ-5D-5L Score), frailty (Clinical Frailty Scale, CFS), pain (visual analogue scale, VAS), anaesthesiologic risk (American Society of Anaesthesiology Score, ASA Score), classification (unified classification system, UCS), type of operation and anaesthesia, in-hospital and early complications (Clavien-Dindo Classification, CDC), and length of stay (LOS). Data were analysed by means of descriptive statistics. Out of 1390 patients treated for any reason, 38 PPFs were included.

RESULTS

Median age was 81 years (range 70-96 years). Twenty-three patients (60.5%) were swabbed on admission, and two of them (5.3%) tested positive; in three patients (7.9%), the diagnosis of COVID-19 was established on a clinical and radiological basis. Two more patients tested positive post-operatively, and one of them died due to COVID-19. Thirty-three patients (86.8%) presented a proximal femoral PPF. Median ASA Score was 3 (range, 1-4), median VAS score on admission was 3 (range, 0-6), median CFS was 4 (range, 1-8), median EQ-5D-5L Score was 3 in each one of the categories (range, 1-5). Twenty-three patients (60.5%) developed post-operative complications, and median CDC grade was 3 (range, 1-5). The median LOS was 12.8 days (range 2-36 days), and 21 patients (55.3%) were discharged home.

CONCLUSIONS

The incidence of PPFs did not seem to change during the lockdown. Patients were mainly elderly with comorbidities, and complications were frequently recorded post-operatively. Despite the difficult period for the healthcare system, hospitals were able to provide effective conventional surgical treatments for PPFs, which were not negatively influenced by the reorganisation. Continued efforts are required to optimise the treatment of these frail patients in the period of the pandemic, minimising the risk of contamination, and to limit the incidence of PPFs in the future.

LEVEL OF EVIDENCE

IV.

Incidence and Risk Factors of In-Hospital Prosthesis-Related Complications Following Total Knee Arthroplasty: A Retrospective Nationwide Inpatient Sample Database Study

Objective

To examine the incidence and risk factors of in‐hospital prosthesis‐related complications (PRCs) following total knee arthroplasty (TKA) using a large‐scale national database.

Methods

A retrospective database analysis was performed based on Nationwide Inpatient Sample (NIS) from 2005–2014. Patients who underwent TKA were included. The recruited cases were divided into two groups according to the occurrence of PRCs. Patient demographics (age, sex, and race), hospital characteristics (type of admission and payer, and bedsize, teaching status, location, and region of hospital), length of stay (LOS), total charges during hospitalization, in‐hospital mortality, comorbidities, and perioperative complications were analyzed.

Results

A total of 1,227,244 TKAs were captured from the NIS database. There were 8484 cases of in‐hospital PRCs after TKA and the overall incidence was 0.69%, with a slight downward trend annually. Periprosthetic joint infection (PJI) was the main category among PRCs (0.20%), followed by mechanical loosening (0.04%), dislocation (0.02%), and periprosthetic fracture (PPF) (0.01%). Patients suffered from in‐hospital PRCs were 3 years younger (64 years vs 67 years) and 6.51% more likely to be male (43.60% vs 37.09%) compared to the nonaffected population (P < 0.0001). Additionally, patients experiencing in‐hospital PRCs after TKA were 2.11% less likely through elective admission (92.07% vs 94.18%) while 2.34% more likely in teaching hospital (45.53% vs 43.19%) than those without these complications (P < 0.0001). Furthermore, the occurrence of in‐hospital PRCs was associated with longer LOS (4 days vs 3 days; P < 0.0001), more total charges ($53,418 vs $41,204, P < 0.0001), and higher in‐hospital mortality (0.30% vs 0.07%; P < 0.0001). Multivariate logistic regression was performed to identify independent risk factors of in‐hospital PRCs after TKA which included younger age, male, non‐elective admission, teaching hospital, deficiency and chronic blood loss anemia, coagulopathy, congestive heart failure, depression, diabetes with chronic complications, fluid and electrolyte disorders, pulmonary circulation disorders, metastatic cancer, and weight loss. Besides, in‐hospital PRCs after TKA were associated with secondary osteoarthritis, inflammatory arthritis, prior knee arthroscopy, acute renal failure, acute myocardial infarction, deep vein thrombosis, sepsis, transfusion, and wound dehiscence.

Conclusion

It is beneficial to study the risk factors of in‐hospital PRCs after TKA to ensure the appropriate management and optimize consequences although a relatively low incidence was identified.

Femoral revision in periprosthetic fractures using a titanium modular fluted tapered stem: mortality and clinical and radiological outcomes

INTRODUCTION

The aim of the study was to evaluate the mortality and the outcomes of femoral revision in periprosthetic femoral fractures (PFF) using a titanium modular fluted tapered stem.

METHODS

We retrospectively reviewed femoral revisions performed for PFF with a titanium modular fluted tapered stem in 25 patients. The average age was 74.32 years. In 21 patients the type of fracture was Vancouver B2 and type B3 in 4 cases. The mean follow-up was 29.16 (0.83-104.1) months SD ± 29.49.

RESULTS

The 30-day and 1-year mortality were 8% and 12% respectively. The mean value of the Charlson Comorbidity Index was 4.8 and the mean value of ASA score was 2.4. The average time to surgery from admittance was 5.45 days with 20% of patients operated on within 48 hours. A significant correlation was found between ASA score and mortality. The mean HHS was 76 points; good-excellent results were recorded in 56% of patients. 72% had no pain and 28% had slight pain (VAS 1-3). 52% of patients were able to walk without pain, limp or aids. The mean implant subsidence was 1.57 mm and superior to 5 mm in 2 cases. As complications we recorded 4 implant dislocations (16%) and 2 infections. Reoperation rate was 12%.

CONCLUSIONS

Femoral revision with a modular fluted tapered stem in patients with periprosthetic fractures results in good clinical and radiological outcomes. However, mortality remains high and, despite the modularity design, dislocation is the most frequent complication.

Is Total Hip Arthroplasty a Cost-Effective Option for Management of Displaced Femoral Neck Fractures? A Trial-Based Analysis of the HEALTH Study

BACKGROUND

Displaced femoral neck fractures are a significant source of morbidity and mortality and can be treated with either hemiarthroplasty (HA) or total hip arthroplasty (THA). Proponents of THA have argued THA offers lower risk of revision, with improved functional outcomes when compared to HA. To evaluate cost effectiveness of THA compared with HA, a trial-based economic analysis of the HEALTH study was undertaken.

METHODS

Health care resource utilization (HRU) and health-related quality of life (HRQoL) data were collected postoperatively and costed using publicly available databases. Using EuroQol-5 Dimensions (EQ-5D) scores, we derived quality adjusted life years (QALYs). A 1.5% discount rate to both costs and QALYs was applied. Age analyses per age group were conducted. All costs are reported in 2019 Canadian dollars.

RESULTS

When compared with HA, THA was not cost-effective for all patients with displaced femoral neck fractures ($150,000/QALY gained). If decision makers were willing to spend $50,000 or $100,000 to gain one QALY, the probability of THA being cost-effective was 12.8% and 32.8%, respectively. In a subgroup of patients younger than 73 (first quartile), THA was both more effective and less costly. Otherwise, THA was more expensive and yielded marginal HRQoL gains.

CONCLUSIONS

Our results suggest that for most patients, THA is not a cost-effective treatment for displaced femoral neck fracture management versus HA. However, THA may be cost effective for younger patients. These patients experience more meaningful improvements in quality of life with less associated cost because of shorter hospital stay and fewer postoperative complications.

LEVEL OF EVIDENCE

Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Postoperative periprosthetic femoral fracture around total hip replacements: current concepts and clinical outcomes

The rising incidence of postoperative periprosthetic femoral fracture (PFF) presents a significant clinical and economic burden.

A detailed understanding of risk factors is required in order to guide preventative strategies.

Different femoral stems have unique characteristics and management strategies must be tailored appropriately.

Consensus regarding treatment of PFFs around well-fixed stems is lacking, but revision surgery may provide more predictable outcomes for unstable fracture patterns and fractures around polished taper-slip stems.

Future research should focus on implant-related risk factors, treatment of concurrent metabolic bone disease and the use of large endoprostheses.

Cite this article: EFORT Open Rev 2020;5:558-567. DOI: 10.1302/2058-5241.5.200003

Predictors of falls in patients during the first year after total hip arthroplasty: A prospective cohort study

BACKGROUND AND PURPOSE

Since falls after total hip arthroplasty (THA) cause severe complications such as dislocation and fractures around the femoral stem, it is important to investigate what factors predict of falls. Thus, investigating predictors of falls in patients waiting for THA would be valuable as it lead to more strategic interventions to prevent these problems. The purpose of this study was to evaluate the predictors of falls in patients during the first year after THA.

METHODS

This is a prospective cohort study. A total of 157 patients who underwent THA for unilateral hip osteoarthritis were analyzed. The incidence of falls during the first year after THA was monitored, and patients were classified into a "faller" and "non-faller" group. The following factors were compared between the two groups: demographic data (age, sex, body mass index, leg length discrepancy, length of hospital stay, and history of falling), preoperative hip abductor muscle strength, functional performance (single leg stance and maximum walking speed), pain during walking, and physical activity.

RESULTS

On multivariate logistic regression analysis, preoperative hip abductor muscle strength on the affected side and a history of falling were predictors of falls during the first year after THA. On subsequent receiver operating characteristic curve analysis, preoperative hip abductor muscle strength on the affected side was retained as a significant predictor, with a cut-off strength of 0.46 Nm/kg differentiating the faller and non-faller groups with a specificity of 73.6%, specificity of 50.0%, and area under the curve of 70.2%.

CONCLUSIONS

Finding from the present study suggested that clinicians should focus on low preoperative hip abductor muscle strength on the affected side and a history of falling to prevent falls during the first year after THA.

Demographics, Treatment, and Cost of Periprosthetic Femur Fractures: Fixation Versus Revision

Introduction:

Periprosthetic femur fractures (PPFX) are complications of both total hip and knee arthroplasty and may be treated with open reduction and internal fixation (ORIF) or revision arthroplasty. Differences in treatment and fracture location may be related to patient demographics and lead to differences in cost. Our study examined the effects of demographics and treatment of knee and hip PPFXs on length of stay (LOS) and cost.

Methods:

Of all, 932 patients were identified with hip or knee PPFXs in the National Inpatient Sample from January 2013 to September 2015. Age, gender, race, mortality, comorbidity level, LOS, total cost, procedure type, geographic region, and hospital type were recorded. A generalized linear regression model was conducted to analyze the effect of fracture type on LOS and cost.

Results:

Differences in gender (66% vs 83.7% female, P < .01), comorbidities (fewer in hips, P < .01), and costs (US$30 979 vs US$27 944, P < .01) were found between the hip and knee groups. Knees had significantly higher rates of ORIF treatment (80.7% vs 39.1%) and lower rates of revision arthroplasties (19.3% vs 60.9%) than hip PPFXs (P < .01). Within both groups, patients with more comorbidities, revision surgery, and blood transfusions were more likely to have a longer LOS and higher cost.

Conclusion:

Periprosthetic femur fractures patients are not homogenous and treatment varies between hip and knee locations. For knee patients, those treated with ORIF were younger, with fewer comorbidities than those treated with revision. Conversely, hip patients treated with ORIF were older, with more comorbidities than those treated with revision. Hips had higher costs than knees, and cost correlated with revision arthroplasty and more comorbidities. In both hip and knee groups, longer LOS was associated with more comorbidities and being treated in urban teaching hospitals. Total cost had the strongest associations with revision procedures as well as number of comorbidities and blood product use.

Projections and Epidemiology of Revision Hip and Knee Arthroplasty in the United States to 2030

BACKGROUND

As the incidence of primary total joint arthroplasty rises in the United States, it is important to investigate how this will impact rates of revision arthroplasty. The purpose of this study was to analyze the incidence and future projections of revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) to 2030. Anticipating surgical volume will aid surgeons in designing protocols to efficiently and effectively perform rTHA/rTKA.

METHODS

The national inpatient sample was queried from 2002 to 2014 for all rTHA/rTKA. Using previously validated measures, Poisson and linear regression analyses were performed to project annual incidence of rTHA/rTKA to 2030, with subgroup analyses on modes of failure and age.

RESULTS

In 2014, there were 50,220 rTHAs and 72,100 rTKAs. From 2014 to 2030, rTHA incidence is projected to increase by between 43% and 70%, whereas rTKA incidence is projected to increase by between 78% and 182%. The 55-64 and 65-74 age groups increased in revision incidence during the study period, whereas 75-84 age group decreased in incidence. For rTKA, infection and aseptic loosening are the 2 most common modes of failure, whereas periprosthetic fracture and infection are most common for rTHA.

CONCLUSION

The incidence of rTHA/rTKA is projected to increase, particularly in young patients and for infection. Given the known risk factor profiles and advanced costs associated with revision arthroplasty, our projections should encourage institutions to generate revision-specific protocols to promote safe pathways for cost-effective care that is commensurate with current value-based health care trends.

LEVEL OF EVIDENCE

IV.

Implant-Related Complications Among Patients With Opioid Use Disorder Following Primary Total Hip Arthroplasty: A Matched-Control Analysis of 42,097 Medicare Patients

BACKGROUND

Opioid use disorders (OUD) are a major cause of morbidity and mortality. The authors of this study hypothesize that patients who have an OUD will have greater relative risk of implant-related complications, periprosthetic joint infections (PJIs), readmission rates, and will incur greater costs compared to non-opioid use disorder (NUD) patients following primary total hip arthroplasty (THA).

METHODS

OUD patients who underwent a THA between 2005 and 2014 were identified and matched to controls in a 1:5 ratio according to age, sex, a comorbidity index, and various medical comorbidities yielding 42,097 patients equally distributed in both cohorts. Pearson's chi-square analyses were used to compare patient demographics. Relative risk (RR) was used to analyze and compare risk of 2-year implant-related complications, 90-day PJIs, and 90-day readmission rates. Welch's t-tests were used to compare day of surgery and 90-day episode-of-care costs between the cohorts. A P value less than .006 was considered statistically significant.

RESULTS

OUD patients had higher incidences and risks of implant-related complications (11.99% vs 6.68%; RR, 1.74; P < .001), developing PJIs within 90 days (2.38% vs 1.81%; RR, 1.32; P = .001), and 90-day readmissions (21.49% vs 17.35%; RR, 1.23; P < .001). Additionally, the study demonstrated OUD patients incurred greater day of surgery ($14,384.30 vs $13,150.12, P < .0001) and 90-day costs ($21,183.82 vs $18,709.02, P < .0001) compared to controls.

CONCLUSION

After controlling for age, sex, a comorbidity index, and various medical complications, OUD patients are at greater risk to experience implant-related complications, PJIs, readmissions, and have greater costs following primary THA compared to non-OUD patients. This study should help orthopedic surgeons counsel their patients of potential complications which may arise following their primary THA.

Defining readmissions among patients undergoing open reduction and internal fixation (ORIF) in claims database analyses

Objective: To evaluate the impact of using different readmissions definitions among patients undergoing open reduction and internal fixation (ORIF) of the femur, tibia, and fibula in claims databases.Methods: Patients from the IBM MarketScan Research Commercial and Medicare Databases receiving inpatient ORIF between 1 January 2010 and 31 January 2017 (index) were identified. Readmissions within 90 days were calculated starting from the index day of discharge to 2 days after discharge. Readmission rates were also reported after accounting for records for rehabilitation, aftercare, or transfer using discharge status, provider type, and Diagnosis Related Group (DRG) codes. For patients with "transferred" as the index hospitalization discharge status, readmissions were calculated 2 days after discharge.Results: A total of 82,692 patients with ORIF for femur, tibia or fibula were identified; mean (SD) age was 60.1 (23.1) years and nearly two-thirds were female (62.3%). For the index hospitalization, 41.6% patients had "transferred" as the discharge status. The readmission rate calculated from the same day as the discharge was 14.7%. Readmission rates calculated 1 and 2 days after index discharge were 8.5 and 7.7%. After accounting for rehabilitation, aftercare and transfer, the corrected readmission rate was 8.6%. Corrected readmission rates calculated 1 and 2 days after index discharge were 7.2 and 7.2%, respectively. The most common diagnosis associated with same day readmission was rehabilitation, whereas that was not observed with readmissions 1 and 2 days after discharge.Conclusions: The accuracy of identifying true admissions was improved by defining readmissions as occurring after the day of discharge and by accounting for rehabilitation, aftercare, and transfer.