Complication Rates of Hemiarthroplasty Conversion to Total Hip Arthroplasty Versus Primary Total Hip Arthroplasty

Conversion of a Failed Hip Hemiarthroplasty to Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

Background

Hip hemiarthroplasty (HA) and total hip arthroplasty (THA) are common treatments for femoral neck fractures in elderly patients. Despite HA's advantages of shorter operative times, less blood loss, and lower initial costs compared to primary THA, it may lead to conversion THA (cTHA). Our objectives are to evaluate the impact of conversion from HA to THA on Harris hip scores (HHS), compare complication rates between cTHA, revision THA, and primary THA, and assess the rates and types of complications following cTHA.

Methods

A systematic review and meta-analysis were performed, evaluating studies published until 2023, with inclusion criteria entailing studies that explored outcomes and complications following cTHA of failed HA. Data extraction focused on variables such as postoperative HHS and complication rates, including periprosthetic joint infection, periprosthetic fracture, dislocation, stem loosening, acetabular loosening, and overall revision.

Results

This study included 28 retrospective studies (4699 hips), showing a mean increase in HHS by 39.1 points, indicating a significant improvement from preoperative levels. Complication rates were detailed, with a 6.4% rate of periprosthetic joint infection, 2.2% for periprosthetic fracture, 7.6% dislocation, 1.6% stem loosening, 1.9% acetabular loosening, and an overall re-revision rate of 8.7%.

Conclusions

Conversion from HA to THA generally results in improved functional outcomes, as evidenced by HHS improvements. Despite the positive impact on HHS, cTHAs are associated with notable risks of complications and the need for further revision surgeries.

Level of Evidence

IV.

National Institute of Health and Care Excellence Guidelines for Displaced Intracapsular Hip Fractures: Examining Satisfaction With the Guidelines and Effects on Outcomes

BACKGROUND

The objectives of the study were to: (1) evaluate satisfaction with the new 2023 National Institute of Health and Care Excellence (NICE) criteria for selecting total hip arthroplasty (THA) over hemiarthroplasty and surgical recommendations for treatment of displaced intracapsular hip fractures; (2) describe why THA is performed when NICE criteria are not met; and (3) determine whether satisfaction with these guidelines is associated with improved outcomes.

METHODS

A retrospective chart review of patients who had a displaced intracapsular hip fracture treated with THA at a single tertiary academic center between 2010 and 2022 was performed. Preoperative patient characteristics were reviewed to determine if the indication for THA met NICE criteria. Operative details, perioperative complications, reoperation, and revision arthroplasty within 12 months of surgery were recorded.

RESULTS

Data from 196 patients (63% women; age 67 ± 10 years) were used. There were 161 THAs (82.1%) that satisfied NICE criteria. The 2 most common reasons for performing a THA when NICE criteria were not met (n = 35) included preoperative radiographic osteoarthritis (Tönnis grade ≥ 2; 48.6%) and decreased patient age (< 65 years; 31.5%). Satisfaction with the NICE criteria was associated with fewer perioperative complications (0.6 versus 37.1%; P < .001), reoperations (0.6 versus 31.4%; P < .001), and revisions (0.6 versus 28.6%; P < .001). The most common reason for revision was periprosthetic fracture, possibly secondary to the use of uncemented femoral stems (171 of 196, 87.2%).

CONCLUSIONS

Satisfaction with the new NICE criteria is associated with improved perioperative outcomes. Further studies are necessary to determine if preexisting hip osteoarthritis and younger age merit consideration in patient selection.

Assessment of Risk Factors and Rate of Conversion to Total Hip Arthroplasty Within 2 Years After Hip Arthroscopy Utilizing a Large Database of Commercially Insured Patients in the United States

Background

The conversion rate of hip arthroscopy (HA) to total hip arthroplasty (THA) has been reported to be as high as 10%. Despite identifying factors that increase the risk of conversion, current studies do not stratify patients by type of arthroscopic procedure.

Purpose/Hypothesis

To analyze the rate and predictors of conversion to THA within 2 years after HA. It was hypothesized that osteoarthritis (OA) and increased patient age would negatively affect the survivorship of HA.

Study Design

Cohort study; Evidence level, 3.

Methods

The IBM MarketScan database was utilized to identify patients who underwent HA and converted to THA within 2 years at inpatient and outpatient facilities between 2013 and 2017. Patients were split into 3 procedure cohorts as follows: (1) femoroacetabular osteoplasty (FAO), which included treatment for femoroacetabular impingement; (2) isolated debridement; and (3) isolated labral repair. Cohort characteristics were compared using standardized differences. Conversion rates between the 3 cohorts were compared using chi-square tests. The relationship between age and conversion was assessed using linear regression. Predictors of conversion were analyzed using multivariable logistic regression. The median time to conversion was estimated using Kaplan-Meier tests.

Results

A total of 5048 patients were identified, and the rates of conversion to THA were 12.86% for isolated debridement, 8.67% for isolated labral repair, and 6.76% for FAO (standardized difference, 0.138). The isolated labral repair cohort had the shortest median time to conversion (isolated labral repair, 10.88 months; isolated debridement, 10.98 months; and FAO, 11.9 months [P = .034). For patients >50 years, isolated debridement had the highest rate of conversion at 18.8%. The conversion rate increased linearly with age. Factors that increased the odds of conversion to THA were OA, having an isolated debridement procedure, and older patient age (P < .05).

Conclusion

Older patients and those with preexisting OA of the hip were at a significantly increased risk of failing HA and requiring a total hip replacement within 2 years of the index procedure. Younger patients were at low risk of requiring a conversion procedure no matter which arthroscopic procedure was performed.

A Matched Comparison of the Rates of Achieving the Minimal Clinically Important Difference Following Conversion and Primary Total Hip Arthroplasty

BACKGROUND

Patient-reported outcome measures (PROMs) are often lower following conversion total hip arthroplasty (cTHA) compared to matched primary total hip arthroplasty (THA) controls. However, the minimal clinically important differences (MCIDs) for any PROMs are yet to be analyzed for cTHA. This study aimed to (1) determine if patients undergoing cTHA achieve primary THA-specific 1-year PROM MCIDs at comparable rates to matched controls undergoing primary THA and (2) establish 1-year MCID values for specific PROMs following cTHA.

METHODS

A retrospective case-control study was conducted using 148 cases of cTHA which were matched 1:2 to 296 primary THA patients. Previously defined anchor values for 2 PROM measures in primary THA were used to compare cTHA to primary THA, while novel cTHA-specific MCID values for 2 PROMs were calculated through a distribution method. Predictors of achieving the MCID of PROMs were analyzed through multivariate logistic regressions.

RESULTS

Conversion THA was associated with decreased odds of achieving the primary THA-specific 1-year Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement PROM (Odds Ratio: 0.319, 95% Confidence Interval: 0.182-0.560, P < .001) and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a PROM (Odds Ratio: 0.531, 95% Confidence Interval: 0.313-0.900, P = .019) MCIDs in reference to matched primary THA patients. Less than 60% of cTHA patients achieved an MCID. The 1-year MCID of the Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a specific to cTHA were +10.71 and +4.68, respectively.

CONCLUSION

While cTHA is within the same diagnosis-related group as primary THA, patients undergoing cTHA have decreased odds of achieving 1-year MCIDs of primary THA-specific PROMs.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

The Association of Postoperative Osteoporosis Therapy With Periprosthetic Fracture Risk in Patients Undergoing Arthroplasty for Femoral Neck Fractures

BACKGROUND

Displaced femoral neck fractures in older adults are generally treated with hip arthroplasty. One concern following hip arthroplasty is the risk for periprosthetic fractures (PPFs). Most patients who have hip fractures are candidates for antiosteoporotic therapy, but the impact of this treatment on PPFs is unknown. Therefore, the primary objective of this study was to evaluate whether patients treated with antiosteoporotic medical therapy had lower odds of PPFs following arthroplasty for hip fracture.

METHODS

Patients at least 65 years old who underwent hip arthroplasty for femoral neck fractures from 2010 to 2020 were identified in a national database. Patients were stratified based on whether they initiated antiosteoporotic therapy within 1 year of hip arthroplasty. Minimum follow-up was 1 year, and maximum follow-up was 10.6 years. The primary endpoint was cumulative incidence of PPF as determined using Kaplan-Meier and Cox proportional hazards regression analyses. Overall, 2,026 patients who underwent arthroplasty for femoral neck fracture received antiosteoporotic medications within 1 year following surgery (mean follow up 4.8 years; range 1.0 to 10.6 years) and 33,639 patients did not (mean follow up 4.1 years; range 1.1 to 10.3 years).

RESULTS

The 10-year cumulative incidence of PPF for patients treated for osteoporosis was 3.88% compared to 5.92% for those who were untreated (P < .001). Adjusting for covariates, patients who received osteoporosis treatment had a significantly lower risk for PPF than those who were untreated (hazard ratio (HR): 0.663; 95% confidence interval (CI): 0.465-0.861; P = .038).

CONCLUSION

The present study suggests that osteoporosis treatment is associated with lower incidence of PPF following hip arthroplasty for femoral neck fractures. Treatment of osteoporosis should be initiated in eligible patients who sustain a femoral neck fracture, especially those who undergo hip arthroplasty.

Risk factors affecting the incidence of postoperative periprosthetic femoral fracture in primary hip arthroplasty patients: a retrospective study

The purpose of this study was to identify the characteristics and risk factors for postoperative periprosthetic femoral fracture (PFF). This was a retrospective cohort study of 108 patients with and 432 control patients without postoperative PFF. Demographic characteristics, surgery-related information (primary hip disease diagnosed, fixation, femoral stem, method of operation, and bone resorption of the proximal femur), and postoperative patient outcomes (hip function, treatment history, and patients' lifestyle behaviors) were recorded and compared between the groups. PFF characteristics, such as the classification, time, and cause, were also documented, and a Cox regression model was built to identify the independent risk factors for postoperative PFF in these patients. Six independent risk factors for postoperative PFF were identified, namely, advanced age (hazard ratio (HR) = 1.026, 95% confidence interval (CI) = 1.007-1.045), femoral neck fracture as the primary disease (HR = 4.536, 95% CI = 2.955-6.961), osteoporosis (HR = 2.043, 95% CI = 1.234-3.383), hemiarthroplasty (or HA, HR = 2.173, 95% CI = 1.327-3.558), bone resorption of the proximal femur (HR = 1.627, 95% CI = 1.090-2.430), and a standard- or long-stem femoral prosthesis (HR = 2.996, 95% CI = 1.480-6.067). The predictive values for a low risk (estimated incidence ≤ 50%), moderate risk (estimated incidence 51%-89%), and high risk (estimated incidence ≥ 90%) of PFF were ≤ 3.0 points, 3.0-10.0 points, and ≥ 10.0 points, respectively. Most patients with postoperative PFF had Vancouver type B fractures. Six independent risk factors for postoperative PFF were identified: advanced age, hip fracture as the primary disease, osteoporosis, HA, bone resorption of the proximal femur, and a long femoral stem.

Mortality and Complications Following Early Conversion Arthroplasty for Failed Hip Fracture Surgery

BACKGROUND

Hip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA.

METHODS

Patients aged 60 years or more undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversions; 247 comparisons) were analyzed for 6-month, 12-month, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications.

RESULTS

Nonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7% conversion versus 6.1% nonconversion, P = .774), 12 months (11% conversion versus 12% nonconversion, P = .999), and 24 months (14% conversion versus 22% nonconversion, P = .163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14% versus 3.2%, P = .001), and medical complications (17% versus 6.1%, P = .006). Inpatient and 90-day orthopaedic complications were similar.

CONCLUSION

Conversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential "second hit" that both surgeons and patients should be aware of with initial decision-making.