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Ng MK, Kobryn A, Emara AK, Krebs VE, Mont MA, Piuzzi NS. Decreasing trend of inpatient mortality rates of aseptic versus septic revision total hip arthroplasty: an analysis of 681,034 cases. Hip Int 2023; 33:1063-1071. [PMID: 36480921 DOI: 10.1177/11207000221140346] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND While most revision total hip arthroplasties (rTHAs) are for aseptic loosening/instability, infection accounts for approximately 16%. The purpose of this study was to: (1) quantify mortality rates of aseptic versus septic rTHA; (2) determine if mortality rates have changed over the past 20 years; and (3) identify associated preoperative risk factors, focusing on the utility/validity of the Elixhauser comorbidity index (ECI). METHODS ICD-9/ICD-10 codes were used to identify patients undergoing rTHA in the National Inpatient Sample database between 1998 and 2017. A total of 681,034 cases (576,143 aseptic THA and 104,891 septic THA) were identified. For each patient, demographic variables including age, sex, race, insurance type, ECI, and inhospital mortality were gathered. A logistic regression model was constructed to assess risk of inhospital mortality. RESULTS From 1998 to 2017, inpatient mortality rates of aseptic and septic rTHA decreased from 0.83 to 0.45%, and from 2.58 to 1.24%, respectively. Septic rTHA was independently associated with higher odds of mortality relative to aseptic (odds ratio (OR): 2.305, 95% confidence interval (CI): (2.014, 2.638), p < 0.0001). Increased ECI was associated with higher odds of mortality at both medium (OR: 5.147, 95% CI: (4.433,5.977), p < 0.0001) and high index scores (OR: 13.714, 95% CI: (11.519,16.326), p < 0.0001). CONCLUSIONS Mortality rates for both aseptic and septic rTHA have been declining over the past 20 years, potentially due to patient selection guidelines and advances in medical management. Our study confirms that the ECI is independently associated with increased inpatient mortality.
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Affiliation(s)
- Mitchell K Ng
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Andriy Kobryn
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Viktor E Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Michael A Mont
- Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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2
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Rullán PJ, Orr MN, Emara AK, Klika AK, Molloy RM, Piuzzi NS. Understanding the 30-day mortality burden after revision total hip arthroplasty. Hip Int 2023; 33:727-735. [PMID: 35578410 DOI: 10.1177/11207000221094543] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Revision total hip arthroplasty (THA) is a challenging procedure that burdens the healthcare system. Despite being associated with worse outcomes relative to its primary counterpart, postoperative mortality after revision THA remains ill-defined. The present study aimed to (1) establish the overall 30-day mortality rate after revision THA and (2) explore the mortality rate stratified by age, comorbidity burden, and aseptic versus septic failure. METHODS The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database was retrospectively reviewed for all patients who underwent revision THA from 2011 to 2019. A total of 23,501 patients were identified and grouped into mortality (n = 161) and mortality-free (n = 23,340) cohorts. Patient demographics, comorbidities, and aseptic/septic failure were evaluated. RESULTS The overall 30-day mortality was 0.69%. The mortality rate by age group (normalised per 1000 patients) was 0 (18-39 years [Y]), 0.67 (40-49 Y), 1.10 (50-59 Y), 2.58 (60-69 Y), 6.15 (70-79 Y) 19.32 (80-89 Y), and 58.22 (90+Y) (p < 0.001). The mortality rate by ASA classification (normalised per 1000 patients) was 0 (ASA I), 1.47 (ASA II), 6.94 (ASA III), 45.42 (ASA IV), and 200 (ASA V) (p < 0.001). The 30-day mortality rate for the septic and aseptic cohorts was 1.03% and 0.65%, respectively (p = 0.038). CCI scores (p < 0.001), diabetes (p < 0.001), systematic sepsis (p < 0.001), poor functional status (p < 0.001), BMI < 24.9 kg/m2 (p < 0.001), and dirty/infected wounds (p < 0.001) were all associated with increased mortality risk. CONCLUSIONS 1 in 145 patients will suffer mortality during the 30 days after revision THA. PJI-related revision THA was associated with 1.5-fold increase in 30-day mortality rate compared to its aseptic counterpart. Certain patient determinants and baseline comorbidities, as measured by ASA and CCI scores, were associated with higher 30-day mortality rates. Therefore, it is imperative to identify such risk factors and implement perioperative patient optimisation pathways to mitigate the risk among vulnerable patients.
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Affiliation(s)
- Pedro J Rullán
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Melissa N Orr
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Yang M, Yan C, Niu N, Lu Y, Yue W, Pan L. Analysis of the Need for Postoperative Drainage Application for Hip Arthroplasty: A Systematic Review and Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:2069468. [PMID: 35251296 PMCID: PMC8894062 DOI: 10.1155/2022/2069468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/10/2022] [Accepted: 01/15/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To synthesize the evidence regarding the effect and safety of drainage after the hip arthroplasty in randomized control trials. BACKGROUND Although the standard of hip replacement has matured in recent years, the need for postoperative drainage is still controversial which also is a clinical problem that needs to be addressed. DESIGN A systematic review and meta-analysis based on the Cochrane methods and Prisma guideline. Data Resources. A systematic search of the Cochrane Library, PubMed, EMBASE, CINAHL, Ovid, Wan Fang database, CNKI, and CBM database was carried out from January 1, 2000, to December, 2021. Review Methods. The quality of included randomized controlled trials was assessed individually by two reviewers independently using criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0. RESULTS Nineteen randomized control trials involving 3354 participants were included in this analysis. From the above analysis, we can know that compared with nondrainage, there was a statistically significant difference in VAS score on the postoperative first day (SD = -0.6; 95% CI: -0.79, -0.41) and second day (SD = -0.38, 95% CI: -0.58, -0.18), hematocrit reduction (MD =2.89; 95% CI: 1.3, 4.48), blood transfusion rate (OR =1.47; 95% CI: 1.12, 1.92), change of thigh circumstance (SMD = -0.48; 95% CI: -0.66, -0.31), and hospital stay (MD = 1.06; 95% CI: 0.73, 1.39) in drainage. However, there were no statistically significant differences in hemoglobin and hematocrit level, hip function, total blood loss, transfusion volume, dressing use, and complications between them. CONCLUSION Drainage after hip arthroplasty can reduce swelling in the thigh and relieve pain while no drainage can bring down hematocrit reduction, decrease dressing uses, and shorten the hospital stay which promotes rapid recovery. This review provides a detailed theoretical reference for the proper clinical application of drains and improves the efficient use of resources.
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Affiliation(s)
- Min Yang
- Department of Nursing, Hainan Provincial Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Traditional Chinese Medicine, Haikou, Hainan 570203, China
| | - Chunwen Yan
- Department of Nursing, Hainan Provincial Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Traditional Chinese Medicine, Haikou, Hainan 570203, China
| | - Nasha Niu
- Department of Nursing, Hainan Provincial Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Traditional Chinese Medicine, Haikou, Hainan 570203, China
| | - Yingzi Lu
- School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510006, China
| | - Wei Yue
- School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510006, China
| | - Li Pan
- Department of Nursing, Hainan Provincial Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Traditional Chinese Medicine, Haikou, Hainan 570203, China
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Laughlin MS, Vidal EA, Drtil AA, Goytia RN, Mathews V, Patel AR. Mortality After Revision Total Hip Arthroplasty. J Arthroplasty 2021; 36:2353-2358. [PMID: 33558045 DOI: 10.1016/j.arth.2021.01.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/04/2021] [Accepted: 01/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In counseling patients about the complications of revision total hip arthroplasty (revTHA), it is imperative that mortality be considered. The actual mortality rate by indication of revision is ill-defined. The purpose of this study is to determine the mortality rate after revTHA. METHODS An institutional database identified 596 patients who had undergone revTHA between 2012 and 2018. Medical records, national, state, and local death indexes were queried for mortality status and indication for revTHA. For survivors, the last clinical visit date was used for censoring in the mortality analysis. Mortality rates were calculated for all clinical patients and then by specific indication for revision. RESULTS The overall 2-year mortality rate following revTHA was 19.5 deaths per 1000 or 1 in 51 patients. Patients presenting with a periprosthetic fracture had a significantly higher 2-year mortality rate of 74.5 deaths per 1000 or 1 in 13 patients (P < .001), while an indication of dislocation or instability had a slightly higher 2-year mortality rate of 50.3 per 1000 (1 in 20) but this difference was not significant (P = .531). Other indications such as mechanical loosening or infection did not have a significantly different mortality rate. CONCLUSION The overall 2-year mortality rate following revTHA was 19.5 deaths per 1000 which was largely attributed to patients with a periprosthetic fracture (74.5 per 1000) with other indications not significantly impacting mortality. Mortality rates and specific rates by indication for revision should be considered when counseling patients prior to revTHA.
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Affiliation(s)
| | - Emily A Vidal
- Fondren Orthopedic Research Institute (FORI), Houston, TX
| | - Arin A Drtil
- Fondren Orthopedic Research Institute (FORI), Houston, TX; Baylor College of Medicine, Houston, TX
| | - Robin N Goytia
- Fondren Orthopedic Research Institute (FORI), Houston, TX; Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX
| | - Vasilios Mathews
- Fondren Orthopedic Research Institute (FORI), Houston, TX; Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX
| | - Anay R Patel
- Fondren Orthopedic Research Institute (FORI), Houston, TX; Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX
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Raad M, Amin R, Puvanesarajah V, Musharbash F, Rao S, Best MJ, Amanatullah DF. The CARDE-B Scoring System Predicts 30-Day Mortality After Revision Total Joint Arthroplasty. J Bone Joint Surg Am 2021; 103:424-431. [PMID: 33475307 PMCID: PMC8832501 DOI: 10.2106/jbjs.20.00969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There exists a substantial risk of having a perioperative complication after revision total joint arthroplasty (TJA). The complex shared decision-making between surgeon and patient would benefit from a high-fidelity tool to identify patients at risk for mortality after revision TJA. Therefore, we developed the CARDE-B score. CARDE-B is an acronym for congestive heart failure, albumin or malnutrition (<3.5 mg/dL), renal failure on dialysis, dependence for daily living, elderly (>65 years of age), and body mass index <25 kg/m2. We developed and validated the CARDE-B score to determine the risk of death within 30 days of a revision TJA. METHODS A total of 13,118 revision TJAs (40% hip and 60% knee) from the National Surgical Quality Improvement Program (NSQIP) database were analyzed. A simple 1-point scoring system, CARDE-B, was created for predicting 30-day mortality after revision TJA, based on a logistic regression model. The CARDE-B scoring system assigns 1 point to each criterion in the acronym: congestive heart failure, albumin (<3.5 mg/dL), renal failure on dialysis, dependence for daily living, elderly (>65 years of age), and body mass index of <25 kg/m2. The CARDE-B scoring system was compared with 2 commonly utilized scores: American Society of Anesthesiologists (ASA) physical status classification and the 5-factor modified frailty index (mFI-5). The area under the curve (AUC) was used to assess the accuracy of each model. The Hosmer-Lemeshow test was used to assess goodness of fit. Finally, the Nationwide Inpatient Sample (NIS) was used for external validation of the CARDE-B score in 19,153 patients who underwent revision TJA in 2017. RESULTS Eighty-eight patients (0.7%) did not survive 30 days after revision TJA. The AUC for the logistic regression model was 0.88 in both the derivation and internal validation samples using NSQIP. The predicted probability of 30-day mortality after revision TJA increased stepwise from <0.01% for a CARDE-B score of 0 points to 39% for a CARDE-B score of 5 points. The AUC for the CARDE-B score predicting 30-day mortality after revision TJA was 0.85. This was more accurate (p < 0.001) than the ASA physical status classification (AUC, 0.77) and the mFI-5 (AUC, 0.67). The AUC for the CARDE-B score in the NIS external validation set was 0.75. The Hosmer-Lemeshow p value for goodness of fit was 0.34, indicating goodness of fit in the external validation sample. CONCLUSIONS The CARDE-B score is a simple system that predicts the risk of death within 30 days of a revision TJA, offering surgeons and patients a valuable and validated risk-stratification tool. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Raj Amin
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Farah Musharbash
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sandesh Rao
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew J. Best
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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6
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Jones MD, Parry M, Whitehouse M, Blom AW. Early death following revision total knee arthroplasty. J Orthop 2019; 19:114-117. [PMID: 32025116 DOI: 10.1016/j.jor.2019.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 11/02/2019] [Indexed: 02/07/2023] Open
Abstract
All patients from our institution who underwent revision total knee arthroplasty (TKA) or were added to the waiting list for revision TKA between 2003 and 2013 were analysed to describe the timing and degree of excess early surgical mortality. We measured the excess surgical mortality at 90-days for the revision TKA group compared to the waiting list group as 0.37% (95% CI 0.10%-0.65%, p = 0.075). A larger sample size will be required to give a more accurate measurement and thus we encourage other authors with access to larger cohorts to use our methods to quantify excess mortality after revision TKA.
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Affiliation(s)
- Mark D Jones
- Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury on Trym, Bristol, BS10 5NB, UK.,Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton, BN2 5BE, UK
| | - Michael Parry
- Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury on Trym, Bristol, BS10 5NB, UK.,The Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP, UK
| | - Michael Whitehouse
- Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury on Trym, Bristol, BS10 5NB, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury on Trym, Bristol, BS10 5NB, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, UK
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Lamb JN, Matharu GS, Redmond A, Judge A, West RM, Pandit HG. Patient and implant survival following intraoperative periprosthetic femoral fractures during primary total hip arthroplasty. Bone Joint J 2019; 101-B:1199-1208. [DOI: 10.1302/0301-620x.101b10.bjj-2018-1596.r1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims We compared implant and patient survival following intraoperative periprosthetic femoral fractures (IOPFFs) during primary total hip arthroplasty (THA) with matched controls. Patients and Methods This retrospective cohort study compared 4831 hips with IOPFF and 48 154 propensity score matched primary THAs without IOPFF implanted between 2004 and 2016, which had been recorded on a national joint registry. Implant and patient survival rates were compared between groups using Cox regression. Results Ten-year stem survival was worse in the IOPFF group (p < 0.001). Risk of revision for aseptic loosening increased 7.2-fold following shaft fracture and almost 2.8-fold after trochanteric fracture (p < 0.001). Risk of periprosthetic fracture of the femur revision increased 4.3-fold following calcar-crack and 3.6-fold after trochanteric fracture (p < 0.01). Risk of instability revision was 3.6-fold after trochanteric fracture and 2.4-fold after calcar crack (p < 0.001). Risk of 90-day mortality following IOPFF without revision was 1.7-fold and 4.0-fold after IOPFF with early revision surgery versus uncomplicated THA (p < 0.001). Conclusion IOPFF increases risk of stem revision and mortality up to ten years following surgery. The risk of revision depends on IOPFF subtype and mortality risk increases with subsequent revision surgery. Surgeons should carefully diagnose and treat IOPFF to minimize fracture progression and implant failure. Cite this article: Bone Joint J 2019;101-B:1199–1208
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Affiliation(s)
- Jonathan N. Lamb
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK
| | - Gulraj S. Matharu
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Anthony Redmond
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Robert M. West
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | - Hemant G. Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
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Cnudde P, Bülow E, Nemes S, Tyson Y, Mohaddes M, Rolfson O. Association between patient survival following reoperation after total hip replacement and the reason for reoperation: an analysis of 9,926 patients in the Swedish Hip Arthroplasty Register. Acta Orthop 2019; 90:226-230. [PMID: 30931668 PMCID: PMC6534231 DOI: 10.1080/17453674.2019.1597062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The association between long-term patient survival and elective primary total hip replacement (THR) has been described extensively. The long-term survival following reoperation of THR is less well understood. We investigated the relative survival of patients undergoing reoperation following elective THR and explored an association between the indication for the reoperation and relative survival. Patients and methods - In this observational cohort study we selected the patients who received an elective primary THR and subsequent reoperations during 1999-2017 as recorded in the Swedish Hip Arthroplasty Register. The selected cohort was followed until the end of the study period, censoring or death. The indications for 1st- and eventual 2nd-time reoperations were analyzed and the relative survival ratio of the observed survival and the expected survival was determined. Results - There were 9,926 1st-time reoperations and of these 2,558 underwent further reoperations. At 5 years after the latest reoperation, relative survival following 1st-time reoperations was 0.94% (95% CI 0.93-0.96) and 0.90% (CI 0.87-0.92) following 2nd-time reoperations. At 5 years patients with a 1st-time reoperation for aseptic loosening had higher survival than expected; however, reoperations performed for periprosthetic fracture, dislocation, and infection had lower survival. Interpretation - The relative survival following 1st- and 2nd-time reoperations in elective THR patients differs by reason for reoperation. The impact of reoperation on life expectancy is more obvious for infection/dislocation and periprosthetic fracture.
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Affiliation(s)
- Peter Cnudde
- Swedish Hip Arthroplasty Register, Gothenburg, Sweden; ,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; ,Department of Orthopaedics, Hywel Dda University Healthboard, Prince Philip Hospital, Llanelli, UK; ,Correspondence:
| | - Erik Bülow
- Swedish Hip Arthroplasty Register, Gothenburg, Sweden; ,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden;
| | - Szilard Nemes
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden;
| | - Yosef Tyson
- Swedish Hip Arthroplasty Register, Gothenburg, Sweden; ,Section of Orthopaedic Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Maziar Mohaddes
- Swedish Hip Arthroplasty Register, Gothenburg, Sweden; ,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden;
| | - Ola Rolfson
- Swedish Hip Arthroplasty Register, Gothenburg, Sweden; ,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden;
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