Chronic Oral Corticosteroid Use and 10-Year Incidence of Major Complications Following Total Knee Arthroplasty

BACKGROUND

Oral corticosteroids are the primary treatment for several autoimmune conditions. The risk of long-term implant, bone health, and infectious-related complications in patients taking chronic oral corticosteroids before total knee arthroplasty (TKA) is unknown. We compared the 10-year cumulative incidence of revision, periprosthetic joint infection (PJI), fragility fracture (FF), and periprosthetic fracture following TKA in patients who had and did not have preoperative chronic oral corticosteroid use.

METHODS

A retrospective cohort analysis was conducted using a national database. Primary TKA patients who had chronic preoperative oral corticosteroid use were identified using Current Procedural Terminology and International Classification of Disease 9 and 10 codes. Exclusion criteria included malignancy, osteoporosis treatment, trauma, and < 2-year follow-up. Primary outcomes were 10-year cumulative incidence and hazard ratios (HRs) of all-cause revision (ACR), aseptic revision, PJI, FF, and periprosthetic fracture. A Kaplan-Meier analysis and a multivariable Cox proportional hazards model were utilized. Overall, 611,596 patients were identified, and 5,217 (0.85%) were prescribed chronic corticosteroids. There were 10,000 control patients randomly sampled for analysis.

RESULTS

Corticosteroid patients had significantly higher 10-year HR of FF (HR; 95% confidence interval); P value (1.47; 1.34 to 1.62; P < .001)], ACR (1.21; 1.05 to 1.40; P = .009), and PJI (1.30; 1.01 to 1.69; P = .045) when compared to the control.

CONCLUSIONS

Patients prescribed preoperative chronic oral corticosteroids had higher risks of ACR, PJI, and FF within 10 years following TKA compared to patients not taking corticosteroids. This information can be used by surgeons during preoperative counseling to educate this high-risk patient population about their increased risk of postoperative complications.

The incremental risk of fragility fractures in aging men

INTRODUCTION

While the United States Preventative Services Task Force recommends osteoporosis screening for women 65 years and older, there is no definitive recommendation for routine osteoporosis screening in men. The purpose of this study was to determine the age at which the odds of fragility fractures (FFx) increase in men to help guide future policy discussions evaluating an optimal screening strategy in this population.

METHODS

Men older than 49 years were identified in the PearlDiver Patient Records Database. Patients were excluded if they had a prior fragility fracture, if they were at high risk for osteoporosis due to comorbidities, or if they carried a diagnosis of and/or were on treatment for osteoporosis. The prevalence of FFx was trended for each age group. A stratum-specific likelihood ratio (SSLR) analysis was conducted to identify data-driven strata that maximize the incremental FFx risk by age for men. Logistic regression analyses controlling for potential confounders were conducted to test these identified strata.

RESULTS

The incidence of FFx started to increase after the age of 64 years for men. Further, the identified data-driven age strata associated with a significant and incremental difference in fragility fractures were the following: 50-64, 65-69, 70-72, 73-75, 76-78, 79-80, and 81+. When compared to the youngest age stratum (50-64 years), multivariable regression showed the risk of fragility fracture incrementally increased starting in those aged 70-72 (RR, 1.31; 95% CI. 1.21-1.46; p < 0.001) with the highest risk in those aged 81+ (RR, 5.35; 95% CI, 5.10-5.62; p < 0.001).

CONCLUSION

In men without a pre-existing history of osteoporosis, the risk of fragility fractures starts to increase after the age of 70. Further work building upon these data may help to identify a specific age at which routine bone health screening in males can help to minimize fractures and their associated morbidity and mortality.

Does Prior Lumbar Fusion Influence Dislocation Risk in Hip Arthroplasty Performed for Femoral Neck Fracture?

BACKGROUND

Immobility of the lumbar spine predicts instability following elective total hip arthroplasty (THA). The purpose of this study is to determine how prior lumbar fusion (LF) influenced dislocation rates and revision rates for patients undergoing THA or hemiarthroplasty (HA) for femoral neck fracture (FNF).

METHODS

A retrospective cohort analysis was conducted utilizing the PearlDiver database from 2010 to 2018. Patients who underwent arthroplasty for FNF were identified based on history of LF and whether they underwent THA or HA. Univariate and multivariate analyses were performed.

RESULTS

A total of 328 patients with prior LF and FNF who underwent THA were at increased risk for 1-year dislocation (odds ratio [OR] 2.19, P < .001) and 2-year revision (OR 2.22, P < .001) compared to 14,217 patients without LF. The 461 patients with prior LF and FNF who underwent HA were at increased risk for dislocation (OR 2.22, P < .001) compared to 42,327 patients without LF. Patients with prior LF and FNF who underwent THA had higher rates of revision than patients with prior LF who underwent HA for FNF (OR 2.11, P < .001). In patients with prior LF and FNF, THA was associated with significantly increased risk for dislocation (OR 3.07, P < .001) and revision (OR 2.53, P < .001) compared to THA performed for osteoarthritis.

CONCLUSION

Patients with prior LF who sustained an FNF and underwent THA or HA were at increased risk for early dislocation and revision compared to those without prior LF. This risk of dislocation and revision is even greater than that observed in patients with prior LF who underwent THA for osteoarthritis.

LEVEL OF EVIDENCE

Level III.

The impact of trauma centre accreditation on patient outcome

Trauma centre accreditation originated as a North American initiative in the 1970's with the aim of standardising and improving care for injured patients. This system of grading a hospital's ability to receive serious trauma has subsequently spread, most notably to Australasia. Many studies have focussed on determing whether this accreditation results in improved patient outcomes. We review the evidence to date, which suggests significant mortality reductions albeit from mainly Class III studies and reflect on the future sustainability of this initiative given mounting financial pressures.