Intraoperative Complications and Early Return to the Operating Room in Total Hip Arthroplasty Performed Through the Direct Anterior and Posterior Approaches. An Institutional Experience of Surgeons After Their Learning Curve

BackgroundProponents of the direct anterior approach (DAA) for total hip arthroplasty (THA) claim a faster recovery, whereas critics claim an increased risk of early femoral complications. This study analyzed intraoperative and postoperative complications requiring reoperation within one year after THA through the DAA and posterior approach (PA).MethodsA total of 2348 elective, unilateral DAA THAs in patients with osteoarthritis performed between 2016 and 2019 were matched 1:1 for age (±5 years), gender, body mass index (±5), and femoral fixation with 2348 patients who underwent PA THA during the same period. Mixed-effects logistic regression was used. Odds ratios were reported for the occurrence of intraoperative femoral fracture, postoperative femoral fracture, infection, dislocation, and other etiologies requiring reoperation within one year.ResultsIntraoperative femoral fracture occurred in 12 DAA (0.5%) and 14 PA (0.6%) patients. Twenty-five patients (1.06%) in the DAA and 28 (1.19%) in the PA group underwent reoperation within the first year. Reoperations were due to periprosthetic fracture (40%), infection (28%), dislocation (23%), and other (9%). Regression analysis revealed no difference in intraoperative femoral fracture (odds ratio (OR): 0.86, 95% confidence interval (CI): 0.40-1.86, P = .69), postoperative femoral fracture (OR: 1.10, 95% CI: 0.47-2.60, P = .83), infection (OR: 1.50, 95% CI: 0.53-5.23, P = .44), or reoperation within one year for other reasons (OR: 1.50, 95% CI: 0.25-9.00, P = .65). DAA had fewer dislocations requiring reoperation (OR: 0.20, 95% CI: 0.04-0.91, P = .02).ConclusionThis comparative study did not find differences in intraoperative or postoperative fracture or infection between DAA and PA. DAA was associated with a lower likelihood of reoperation for dislocation within one year of surgery.     

Differential Use of Narcotics in Total Hip Arthroplasty: A Comparative Matched Analysis Between Osteoarthritis and Femoral Neck Fracture

BackgroundThe United States is currently in an opioid epidemic as it consumes the majority of narcotic medications. The purpose of this investigation is to identify the incidence and risk factors for prolonged opioid usage following total hip arthroplasty (THA) due to hip fracture (Fx) or osteoarthritis (OA).MethodsThe PearlDiver database was reviewed for patients undergoing THA from 2007 through the first quarter of 2017. Following a 3:1 match based on comorbidities and demographics, patients were divided into THA due to Fx (n = 1801) or OA (n = 5403). Preoperative and prolonged postoperative narcotic users were identified. Multivariate logistic regression analysis was performed to identify demographics, comorbidities, or diagnoses as risk factors for prolonged opioid use and preoperative and postoperative opioid use as risk factors for complications.ResultsOne thousand seven hundred ninety-four OA patients (33.2%) were prescribed narcotics preoperatively and 1655 patients (30.6%) were using narcotics postoperatively, while 418 Fx patients (23.2%) were prescribed narcotics preoperatively and 499 patients (27.7%) were using narcotics postoperatively. Diagnosis of Fx (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.28-1.72, P < .001) and preoperative narcotic use (OR 6.12, 95% CI 5.27-6.82, P < .001) were the most significant risk factors for prolonged postoperative narcotic use. Prolonged postoperative narcotic use was associated with increased infection, dislocation, and revision THA in both Fx and OA groups.ConclusionDiagnosis of femoral neck fracture and overall preoperative narcotic use were significant predictors of chronic postoperative opioid use. Patients with significant risk factors for opioid dependence should receive additional consultation and more prudent follow-up with regards to pain management.Level of EvidenceTherapeutic, Level III.     

Patient Characteristics Influence Revision Rate of Total Hip Arthroplasty: American Society of Anesthesiologists Score and Body Mass Index Were the Strongest Predictors for Short-Term Revision After Primary Total Hip Arthroplasty

BackgroundOutcome and survival after primary total hip arthroplasty (THA) can be affected by patient characteristics. We examined the effect of case-mix on revision after primary THA using the Dutch Arthroplasty Register.MethodsOur cohort included all primary THAs (n = 218,214) performed in patients with osteoarthritis in the Netherlands between 2007 and 2018. Multivariable logistic regression analysis was used to calculate the difference in survivorship in patients with different patient characteristics (age, gender, American Society of Anesthesiologists [ASA] score, body mass index [BMI], Charnley score, smoking, and previous operations to the hip).ResultsCase-mix factors associated with an increased risk for revision 1 year after THA were the following: a high ASA score (II and III-IV) (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1-2.0 and OR 3.0, 95% CI 1.7-5.3), a higher BMI (30-40 and >40) (OR 1.4, 95% CI 1.2-1.5 and OR 2.0, 95% CI 1.4-1.7), age ≥75 years (OR 1.5, 95% CI 1.1-2.0), and male gender (OR 1.3, 95% CI 1.2-1.4). A similar model for 3-year revision showed comparable results. High BMI (OR 1.9, 95% CI 1.3-2.9), a previous hip operation (OR 1.8, 95% CI 1.3-2.5), ASA III-IV (OR 1.2, 95% CI 1-1.6), and Charnley score C (OR 1.5, 95% CI 1.1-2.2) were associated with increased risk for revision. Main reasons for revision in obese and ASA II-IV patients were infection, dislocation, and periprosthetic fracture. Patients with femoral neck fracture and late post-traumatic pathology were more likely to be revised within 3 years, compared to osteoarthritis patients (OR 1.5, 95% CI 1.3-1.7 and OR 1.5, 95% CI 1.2-1.7).ConclusionThe short-term risk for revision after primary THA is influenced by case-mix factors. ASA score and BMI (especially >40) were the strongest predictors for 1-year revision after primary THA. After 3 years, BMI and previous hip surgery were independent risk factors for revision. This will help surgeons to identify and counsel high-risk patients and take appropriate preventive measures.     

Total Hip Arthroplasty in Patients With Osteopetrosis

BackgroundOsteopetrosis is an inherited bone disease associated with high risk of osteoarthritis and fracture non-union, which can lead to total hip arthroplasty (THA). Bone quality and morphology are altered in these patients, and there are limited data on results of THA in these patients. The goals of this study were to describe implant survivorship, clinical outcomes, radiographic results, and complications in patients with osteopetrosis undergoing primary THA.MethodsWe identified 7 patients (9 hips) with osteopetrosis who underwent primary THA between 1970 and 2017 utilizing our total joint registry. The mean age at index THA was 48 years and included two males and five females. The mean follow-up was 8 years.ResultsThe 10-year survivorship free from any revision or implant removal was 89%, with 1 revision and 1 resection arthroplasty secondary to periprosthetic femoral fractures. The 10-year survivorship free from any reoperation was 42%, with 4 additional reoperations (2 ORIFs for periprosthetic femoral fractures, 1 sciatic nerve palsy lysis of adhesions, 1 hematoma evacuation). Harris hip scores significantly increased at 5 years (P = .04). Five hips had an intraoperative acetabular fracture, and 1 had an intraoperative femur fracture. All postoperative femoral fractures occurred in patients with intramedullary diameter less than 5 mm at a level 10 cm distal to the lesser trochanter.ConclusionPrimary THA in patients with osteopetrosis is associated with good 10-year implant survivorship (89%), but a very high reoperation (58%) and periprosthetic femoral fracture rate (44%). Femoral fractures appear associated with smaller intramedullary diameters.     

Preoperative Patient Factors and Postoperative Complications as Risk Factors for New-Onset Depression Following Total Hip Arthroplasty

BackgroundDepression is known to be a risk factor for complication following primary total hip arthroplasty (THA), but little is known about new-onset depression (NOD) following THA. The purpose of this study is to determine the incidence of NOD and identify risk factors for its occurrence after THA.MethodsThis is a retrospective cohort study of the Truven MarketScan database. Patients undergoing primary THA were identified and separated into cohorts based on the presence or not of NOD. Patients with preoperative depression or a diagnosis of fracture were excluded. Patient demographic and comorbid data were queried, and postoperative complications were collected. Univariate and multivariate regression analysis was then performed to assess the association of NOD with patient-specific factors and postoperative complications.ResultsIn total, 111,838 patients undergoing THA were identified and 2517 (2.25%) patients had NOD in the first postoperative year. Multivariate analysis demonstrated that preoperative opioid use, female gender, higher Elixhauser comorbidity index, preoperative anxiety disorder, drug or alcohol use disorder, and preoperative smoking were associated with the occurrence of NOD (P ≤ .001). The following postoperative complications were associated with increased odds of NOD: prosthetic joint infection (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.42-2.34, P < .001), aseptic revision surgery (OR 1.47, 95% CI 1.06-2.04, P = .019), periprosthetic fracture (OR 1.72, 95% CI 1.13-2.61, P = .01), and non-home discharge (OR 1.59, 95% CI 1.42-1.77, P < .001).ConclusionsNOD is common following THA and there are multiple patient-specific factors and postoperative complications which increase the odds of its occurrence. Providers should use this information to identify at-risk patients so that pre-emptive prevention strategies may be employed.     

Increased Complications and Cost Associated With Hip Arthroplasty for Femoral Neck Fracture: Evaluation of 576,119 Medicare Patients Treated With Hip Arthroplasty

BackgroundThe benefit of total hip arthroplasty (THA) for treatment of osteoarthritis (OA) and femoral neck fractures (FNFs) in the geriatric population is well established. We compare perioperative complications and cost of THA for treatment of OA to hemiarthroplasty (HA) and THA for treatment of FNF.MethodsData from the Centers for Medicare & Medicaid Services were used to identify all patients 65 years and older undergoing primary hip arthroplasty between 2013 and 2017. Patients were divided into 3 cohorts: THA for OA (n = 326,313), HA for FNF (n = 223,811), and THA for FNF (n = 25,995). Generalized regressions were used to compare group mortality, 90-day readmission, thromboembolic events, and 90-day episode costs, controlling for age, gender, race, and comorbidities.ResultsCompared to patients treated for OA, FNF patients were older and had significantly more comorbidities (all P < .001). Even among the youngest age group (65-69 years) without comorbidities, FNF was associated with a greater risk of mortality at 90 days (THA-FNF odds ratio [OR] 9.3, HA-FNF OR 27.0, P < .001), 1 year (THA-FNF OR 7.8, HA-FNF OR 19.0, P < .001) and 5 years (THA-FNF hazard ratio 4.5, HA-FNF hazard ratio 10.0, P < .001). The average 90-day direct cost was $12,479 and $14,036 greater among THA and HA for FNF respectively compared to THA for OA (all P < .001).ConclusionAmong Centers for Medicare & Medicaid Services hip arthroplasty patients, those with an FNF had significantly higher rates of mortality, thromboembolic events, readmission, and greater direct cost. Reimbursement models for arthroplasty should account for the distinctly different perioperative complication and resource utilization for FNF patients.     

Effect of Sickle Cell Trait on Total Hip Arthroplasty in a Matched Cohort

BackgroundIt is unclear if sickle cell trait (SCT) carrier status conveys an increased risk for poor outcomes following total hip arthroplasty (THA). The purpose of this study is to compare short-term clinical outcomes of THA for patients with SCT vs matched controls.MethodsPatient records were queried from the PearlDiver database using International Classification of Diseases, Ninth and Tenth Revision and Current Procedural Terminology codes. Patients with SCT who underwent THA were matched 1:1 with controls across age, gender, Elixhauser Comorbidity Index, obesity, and US region. Thirty-day and 90-day rates of systemic complications and 1-year and 2-year rates of joint complications were compared with logistic regression.ResultsIn total, 1646 patients were assigned to each cohort. In the 30-day and 90-day postoperative periods, SCT carriers had a higher likelihood of cerebrovascular accident, anemia, acute renal failure, pneumonia, sepsis, deep vein thrombosis, pulmonary embolism, and respiratory failure (all P < .05). SCT carriers exhibited significantly higher risk of periprosthetic joint infection at both 1 (3.5% vs 2.1%; odds ratio [OR] 1.91, 95% confidence interval [CI] 1.22-2.99) and 2 years (3.7% vs 2.6%; OR 1.63, 95% CI 1.07-2.49) postoperatively. Prosthetic loosening was also significantly more likely for SCT carriers within 1 year (1.3% vs 0.3%; OR 4.49, 95% CI 1.75-13.86).ConclusionPatients with SCT exhibited significantly higher risk for systemic complications, periprosthetic joint infection, and prosthetic loosening after THA. Increased perioperative efforts should be made to prevent hypoxia, acidosis, and dehydration, as these states increase red blood cell sickling, which may reduce complication rates and improve outcomes in patients with SCT.     

Persistent Wound Drainage among Total Joint Arthroplasty Patients Receiving Aspirin vs Coumadin

BackgroundPersistent wound drainage (PWD) is one of the major risk factors for periprosthetic joint infections (PJI), arguably the most dreaded complications after a total hip and knee arthroplasty (THA and TKA). The aim of this study is to identify the rates of PWD among THA and TKA patients who received aspirin (ASA) or Coumadin for postoperative venous thromboembolism (VTE) prophylaxis.MethodsRetrospective review of 5516 primary THA and TKA was performed. Patients with PWD were identified. Chi-square test was used to compare the incidences of PWD, 30-day VTE, and PJI at 6 months between the ASA and Coumadin groups. Multivariate regression model was used to identify independent risk factors for PWD using Charlson and Elixhauser comorbidity indexes.ResultsThe prevalence of PWD was 6.4% (353/5516). Patients receiving ASA had lower incidence of PWD (3.2% vs 8.5%, P < .0001) while having comparable rates of 30-day VTE (1.3% vs 1.4%, P = .722) and PJI at 6 months (1.8% vs 1.4%, P = .233) compared to those receiving Coumadin. Risk factors for PWD were diabetes (odds ratio [OR], 19.3; 95% confidence interval [CI], 11.8-23.2), rheumatoid arthritis (OR, 15.3; 95% CI, 10.8-17.2), morbid obesity (OR, 13.2; 95% CI, 9.7-17.5), chronic alcohol use (OR, 3.5; 95% CI, 1.8-5.5), hypothyroidism (OR, 1.9; 95% CI, 1.1-3.2), and Coumadin (OR, 1.7; 95% CI, 1.2-2.2).ConclusionUse of ASA is associated with significantly lower rates of PWD after THA and TKA when compared to Coumadin while being equally efficacious at preventing VTE. Coumadin was found to be an independent risk factor for PWD.     

Rural Hospital Designation Is Associated With Increased Complications and Resource Utilization After Primary Total Hip Arthroplasty: A Matched Case-Control Study

BackgroundAs the prevalence of hip osteoarthritis increases, the demand for total hip arthroplasty (THA) has grown. It is known that patients in rural and urban geographic locations undergo THA at similar rates. This study explores the relationship between geographic location and postoperative outcomes.MethodsIn this retrospective cohort study, the Truven MarketScan database was used to identify patients who underwent primary THA between January 2010 and December 2018. Patients with prior hip fracture, infection, and/or avascular necrosis were excluded. Two cohorts were created based on geographic locations: urban vs rural (rural denotes any incorporated place with fewer than 2500 inhabitants). Age, gender, and obesity were used for one-to-one matching between cohorts. Patient demographics, medical comorbidities, postoperative complications, and resource utilization were statistically compared between the cohorts using multivariate conditional logistic regression.ResultsIn total, 18,712 patients were included for analysis (9356 per cohort). After matching, there were no significant differences in comorbidities between cohorts. The following were more common in rural patients: dislocation within 1 year (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.08-1.41, P < .001), revision within 1 year (OR 1.17, 95% CI 1.05-1.32, P = .027), and prosthetic joint infection (OR 1.14, 95% CI 1.04-1.34, P = .033). Similarly, rural patients had higher odds of 30-day readmission (OR 1.31, 95% CI 1.09-1.56, P = .041), 90-day readmission (OR 1.41, 95% CI 1.26-1.71, P = .023), and extended length of stay (≥3 days; OR 1.52, 95% CI 1.22-1.81, P < .001).ConclusionTHA in rural patients is associated with increased cost, healthcare utilization, and complications compared to urban patients. Standardization between geographic areas could reduce this discrepancy.     

Periprosthetic Femoral Fractures in Cementless Short Versus Straight Stem Total Hip Arthroplasty: A Propensity Score Matched Analysis

BackgroundRecent studies indicate a decreased risk of periprosthetic femoral fractures (PFFs) in cementless total hip arthroplasty (THA) for short compared to straight stems. However, the results are still inconclusive. Therefore, we retrospectively investigated the rate of PFFs within the first year between cementless short and straight stem THA.MethodsA 1:1 propensity score matching of 3,053 THAs was performed. Two groups including 1,147 short stem THAs implanted through a minimally invasive antero-lateral approach and 1,147 straight stem THAs implanted through a transgluteal Hardinge approach were matched. The rates of PFFs and fracture patterns were compared between both stem types. Risk factors for PFFs were analyzed by multivariate regression analyses.ResultsThe overall rate of PFFs was 1.7% in short stem THA and 3.2% in straight stem THA (P = .015). Postoperatively detected Vancouver A fractures occurred significantly more often in straight stem THA (P = .002), while the occurrence Vancouver B fractures did not differ significantly (P = .563). The risk of PFFs was significantly increased for women in straight stem THA (Odds ratio (OR) 2.620; Confidence Interval (CI) 1.172-5.856; P = .019). Increasing age showed a significantly increased odds ratio in short stem (OR 1.103; CI 1.041-1.169, P < .001) and straight stem THA (OR 1.057; CI 1.014-1.101, P = .008).ConclusionShort stem THA reduces Vancouver Type A PFFs in the trochanteric region compared to straight stem THA, while Vancouver Type B fractures are comparable. Increasing age is a significant risk factor for both stem types, while the risk for PFFs in women was only significantly increased in the straight stem group.     

What Factors Affect Whether Patients Return to the Same Surgeon to Replace the Contralateral Joint? A Study of Over 200,000 Patients

BackgroundPatients with hip and knee arthritis often undergo bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) in a staged or simultaneous fashion. However, when staged, the incidence and factors associated with having both procedures performed by the same surgeon or different surgeon are not well studied.MethodsAll patients undergoing nonsimultaneous bilateral THA or TKA for osteoarthritis were abstracted from the 2010 to 2020 PearlDiver Mariner administrative database. The National Provider Identifier number was used to determine whether the same surgeon performed both surgeries. Demographics, comorbidities, and 90-day complications after the first joint replacement were assessed as possible independent predictors of utilizing a different surgeon for the contralateral joint.ResultsOf 87,593 staged bilateral THAs, the same surgeon performed 40,707 (46.5%) arthroplasties. Of 147,938 staged bilateral TKAs, the same surgeon performed 77,072 (52.1%) arthroplasties. Notably, older cohorts of patients had independent, stepwise, and significantly greater odds of changing surgeons for the contralateral THA and TKA. Those patients who were insured by Medicare and Medicaid had significantly lower odds of changing surgeons. For both THA and TKA, surgical and implant-related adverse events (surgical site infection/periprosthetic joint infection, periprosthetic fracture, dislocation, manipulation) carried the greatest odds of undergoing the contralateral replacement with a different surgeon.ConclusionPatients covered by Medicaid and sicker patients were significancy less likely to switch surgeons for their contralateral THA or TKA. Additionally, patients experiencing a surgery-related adverse event within 90 days of their first THA or TKA had significantly, increased odds of switching surgeons for their subsequent TJA.     

Disparities in Elective and Nonelective Total Hip Arthroplasty

BackgroundPrior studies have shown disparities in utilization of primary and revision total hip arthroplasty (THA). However, little is known about patient population differences associated with elective and nonelective surgery. Therefore, the aim of this study was to explore factors that influence primary utilization and revision risk of THA based on surgery indication.MethodsData were obtained from 7,543 patients who had a primary THA from 2014 to 2020 in a database, which consists of multiple health partner systems in Louisiana and Texas. Of these patients, 602 patients (8%) underwent nonelective THA. THA was classified as “elective” or “nonelective” if the patient had a diagnosis of hip osteoarthritis or femoral neck fracture, respectively.ResultsAfter multivariable logistic regression, nonelective THA was associated with alcohol dependence, lower body mass index (BMI), women, and increased age and number of comorbid conditions. No racial or ethnic differences were observed for the utilization of primary THA. Of the 262 patients who underwent revision surgery, patients who underwent THA for nonelective etiologies had an increased odds of revision within 3 years of primary THA (odds ratio (OR) = 1.66, 95% Confidence Interval (CI) = 1.06-2.58, P-value = .025). After multivariable logistic regression, patients who had tobacco usage (adjusted odds ratio (aOR) = 1.36, 95% CI = 1.04-1.78, P-value = .024), alcohol dependence (aOR = 2.46, 95% CI = 1.45-4.15, P-value = .001), and public insurance (OR = 2.08, 95% CI = 1.18-3.70, P-value = .026) had an increased risk of reoperation.ConclusionDemographic and social factors impact the utilization of elective and nonelective primary THA and subsequent revision surgery. Orthopaedic surgeons should focus on preoperative counseling for tobacco and alcohol cessation as these are modifiable risk factors to directly decrease reoperation risk.     

Total hip replacement after femoral neck fractures in elderly patients : Results of 8,577 fractures reported to the Norwegian Arthroplasty Register

Background?A total hip arthroplasty (THA) is often used as treatment for failed osteosynthesis of femoral neck fractures and is now also used for acute femoral neck fractures. To investigate the results of THA after femoral neck fractures, we used data from the Norwegian Arthroplasty Register (NAR).

Patients and methods?The results of primary total hip replacements in patients with acute femoral neck fractures (n = 487) and sequelae after femoral neck fractures (n = 8,090) were compared to those of total hip replacements in patients with osteoarthrosis (OA) (n = 55,109). The hips were followed for 0–18 years. The Cox multiple regression model was used to construct adjusted survival curves and to adjust for differences in sex, age, and type of cement among the diagnostic groups. Separate analyses were done on the subgroups of patients who were operated with Charnley prostheses.

Results?The survival rate of the implants after 5 years was 95% for the patients with acute fractures, 96% for the patients with sequelae after fracture, and 97% for the OA patients. With adjustment for age, sex, and type of cement, the patients with acute fractures had an increased risk of revision compared to the OA patients (RR 1.6, 95% CI: 1.0–2.6; p = 0.05) and the sequelae patients had an increased risk of revision (RR 1.3, 95% CI: 1.2–1.5; p < 0.001). Sequelae hips had higher risk of revision due to dislocation (RR 2.0, 95% CI: 1.6–2.4; p < 0.001) and periprosthetic fracture (RR 2.2, 95% CI: 1.5–3.3; p < 0.001), and lower risk of revision due to loosening of the acetabular component (RR 0.72, 95% CI; 0.57–0.93; p = 0.01) compared to the OA patients. The increased risk of revision was most apparent for the first 6 months after primary operation.

Interpretation?THA in fracture patients showed good results, but there was an increased risk of early dislocations and periprosthetic fractures compared to OA patients.     

No Difference Between Hemiarthroplasty and Total Hip Arthroplasty in the Treatment of Pathologic Femoral Neck Fractures

BackgroundHemiarthroplasty (HA) and total hip arthroplasty (THA) have been widely discussed as treatment options for displaced osteoporotic femoral neck fractures. Pathologic femoral neck fractures from primary or metastatic tumors are comparatively rare and poorly investigated. The purpose of this study was to compare outcomes, complications, and perioperative survival for HA and THA in the treatment of pathologic femoral neck fractures of neoplastic etiology.MethodsA multicenter retrospective cohort study identified patients with pathologic femoral neck fractures treated with HA or THA from 2005 to 2018. Demographics, American Society of Anesthesiologists classification, Charlson comorbidity index, Dorr classification, histopathologic diagnosis, and surgical data were compared. The primary outcome was reoperation. Secondary outcomes included 90-day mortality, estimated blood loss, length of stay, periprosthetic fracture, periprosthetic joint infection, and Eastern Cooperative Oncology Group performance status.ResultsThere were 116 patients with HA and 48 patients with THA, with no differences between groups with regard to American Society of Anesthesiologists classification, Charlson comorbidity index, or Dorr classification. There were no differences between HA and THA in the primary outcome of reoperation (5.2% vs 4.2%, P = 1.00) or secondary outcomes of perioperative 90-day overall mortality (30.2% vs 25.0%, P = .51), estimated blood loss, transfusion rates, length of stay, discharge location, periprosthetic joint infection, periprosthetic fracture, or preoperative or postoperative Eastern Cooperative Oncology Group performance status.ConclusionsBoth HA and THA are viable options for the treatment of patients with pathologic femoral neck fractures and demonstrated no differences in reoperations, complications, perioperative 90-day mortality, or functional outcome scores.Level of EvidenceLevel III.     

Cementless Total Hip Arthroplasty for Adult Patients With Sequelae From Childhood Hip Infection: A Medium-Term Follow-Up Study

BackgroundThe aim of this study is to evaluate midterm clinical and radiographic results of total hip arthroplasties (THAs) with cementless implants for adult patients with sequelae from childhood hip infection.MethodsBetween 2002 and 2016, 165 patients (165 hips) who had a hip infection during childhood were treated with THAs with cementless implants. The average duration of follow-up was 93.5 months (range 26-206). Clinical results were evaluated via the Harris Hip Score and radiographic results were analyzed with postoperative serial X-rays.ResultsThe average Harris Hip Score increased from 27 (range 8-53) before surgery to 91 (range 45-100) at the latest follow-up examination (P < .001). At the latest follow-up evaluation, 9 cementless acetabular components demonstrated partial, nonprogressive radiolucencies. No subsidence of more than 2 mm or evidence of a radiolucent line was observed around the femoral components. Intraoperative periprosthetic fractures occurred in 11 hips, including 3 acetabular fractures, 2 fractures of greater trochanter, 1 femoral shaft fracture, and 5 fractures of femoral calcar. Postoperative complications included 3 cases of periprosthetic infection, 1 episode of dislocation, 1 case of a femoral periprosthetic fracture, 5 cases of sciatic nerve injury, 1 case of femoral nerve injury, and 1 case of squeaking from a ceramic bearing surface.ConclusionCementless THA for adult patients with sequelae from childhood hip infection presents significant technical challenges and a relatively high complication rate. With meticulous surgical planning and anticipation for the key technical challenges frequently encountered, the medium-term clinical and radiographic results of THA in this setting were good with high implant survivorship and patient satisfaction.     

Risk factors for implant failure after fixation of proximal femoral fractures with fracture of the lateral femoral wall

IntroductionTo investigate potential predictors of implant failure following fixation of proximal femoral fractures with a fracture of the lateral femoral wall.Materials and methodsMedical records of 99 adult patients who had operative treatment for a proximal femoral fracture with a fracture of the lateral femoral wall between May 2004 and April 2015 were retrospectively analysed to determine factors associated with implant failure. Patients underwent routine surgical procedures for implantation of extramedullary or intramedullary devices. Potential predictors were age, gender, body mass index, comorbidities, type of fracture, reduction method, status of greater and lesser trochanters, course of the lateral fracture line, and presence/absence of a free bone fragment at the junction of the greater trochanter and lateral femoral wall.ResultsTen (10%) implant failures were identified. Univariate analysis identified a free bone fragment at the junction of the greater trochanter and lateral femoral wall (odds ratio [OR], 21.25; 95% confidence interval [CI], 4.31–104.67; p < 0.001) and a transverse fracture line across the lateral femoral wall (primary or iatrogenic) (OR, 5.36; 95% CI, 1.29–22.30; p = 0.021) as factors associated with implant failure. Using a multivariate model, only a free bone fragment at the junction of the greater trochanter and lateral femoral wall (OR, 16.05; 95% CI, 3.06–84.23; p = 0.001) was a risk factor for implant failure.ConclusionsA free bone fragment at the junction of the greater trochanter and lateral femoral wall and a transverse fracture line across the lateral femoral wall are predictors of implant failure in proximal femoral fractures with a fracture of the lateral femoral wall. Integrity of the lateral femoral wall correlates with prognosis of proximal femoral fracture. Lateral femoral wall reconstruction may be required for effective treatment of proximal femoral fractures with a fracture of the lateral femoral wall.     

Total Hip Arthroplasty in Patients Who Have Respiratory Disease Who use Supplemental Home Oxygen

BackgroundThe purpose of this study is to investigate the association between supplemental home oxygen prior to surgery and both medical and surgical complications after primary elective total hip arthroplasty (THA) in patients who have respiratory disease (RD).MethodsThe Mariner database was used to identify patients who have RD who received primary elective THA from 2010 to 2020. The THA patient cohorts consisted of 20,872 patients who had RD prescribed home oxygen and 69,520 patients who had RD without home oxygen. For patients who had a diagnosis of RD and were prescribed supplemental home oxygen (O2) and those who were not, the rates of postoperative medical and surgical complications, hospital readmissions, and emergency room visits were determined. Reimbursements and lengths of stay were also determined. Logistic regression analyses were utilized to compare both cohorts to matched cohorts without RD, as well as to each other directly.ResultsIn comparison to the matched control group, the RD with home oxygen group had a significantly higher rate of pneumonia (odds ratio [OR] 4.27, P < .0001), pulmonary embolism (OR 1.81, P < .0001), periprosthetic joint infection (OR 1.21, P < .0001), and periprosthetic fracture (OR 1.81, P = .001). The RD with home oxygen cohort also had a significantly higher incidence of pneumonia (OR 2.16, P < .0001), periprosthetic joint infection (OR 1.38, P < .0001), and periprosthetic fracture (OR 1.24, P = .009) compared to RD patients who did not have home oxygen.ConclusionSupplemental home oxygen use prior to surgery is associated with a significantly higher risk of postoperative medical and surgical complications after elective THA.     

Preoperative Corticosteroid Injections Demonstrate a Temporal and Dose-Dependent Relationship with the Rate of Postoperative Infection Following Total Hip Arthroplasty

BackgroundCorticosteroid injections (CSI) are commonly used for the treatment of osteoarthritis of the hip. There is concern, however, that these injections may increase the risk of postoperative infection if a subsequent total hip arthroplasty (THA) is performed. The purpose of the present investigation is to determine the relationship between CSI and the risk of periprosthetic joint infection (PJI) and surgical site infections (SSIs) following THA.MethodsThe PearlDiver database was reviewed for patients undergoing THA from 2011 to 2018. Patients with unilateral hip osteoarthritis who received an intra-articular hip CSI prior to ipsilateral THA were matched in a sequential 1:1 fashion based on age, gender, and Charlson Comorbidity Index with THA patients who did not receive an injection in the preoperative period. PJI and SSI within 6 months of the surgical procedure were recorded. Statistical analysis included chi-squared test and multivariate logistic regression. Results were considered significant at P < .05.ResultsIn total, 29,058 patients underwent a hip CSI within 6 months prior to THA. CSI within 4 months of surgery was associated with a higher incidence of PJI at 6-month follow up (1.6% vs 1.1%, P = .040). An injection within 1 month of surgery corresponded to a higher odds of PJI (odds ratio [OR] 1.97) than an injection 4 months prior to surgery (OR 1.24). Furthermore, the quantity of CSI administered within the 3 months prior to THA demonstrated a dose-dependent relationship, with each subsequent injection increasing odds of PJI (OR 1.45-3.59). A similar relationship was observed for SSI.ConclusionThere appears to be both a time and dose-dependent association of hip CSI and PJI following THA. Surgeons should consider delaying elective THA if a CSI has been administered within the 4 months prior to the planned procedure.     

Comparison of the Efficacy Between Closed Incisional Negative-Pressure Wound Therapy and Conventional Wound Management After Total Hip and Knee Arthroplasties: A Systematic Review and Meta-Analysis

BackgroundWound-related problems after total hip arthroplasty (THA) and total knee arthroplasty (TKA) can cause periprosthetic joint infections. We sought to evaluate the effect of closed incisional negative-pressure wound therapy (ciNPWT) on wound complications, skin blisters, surgical site infections (SSIs), reoperations, and length of hospitalization (LOH).MethodsStudies comparing ciNPWT with conventional dressings following THA and TKA were systematically searched on MEDLINE, Embase, and the Cochrane Library. Two reviewers performed the study selection, risk of bias assessment, and data extraction. Funnel plots were employed to evaluate publication bias and forest plots to analyze pooled data.ResultsTwelve studies were included herein. The odds ratios (ORs) for wound complications and SSIs indicated a lack of publication bias. ciNPWT showed significantly lower risks of wound complication (OR, 0.44; 95% confidence interval [CI], 0.22-0.9; P = .027) and SSI (OR, 0.39; 95% CI, 0.23-0.68; P < .001) than did conventional dressings. ciNPWT also yielded a significantly lower reoperation rate (OR, 0.38; 95% CI, 0.21-0.69; P = .001) and shorter LOH (mean difference, 0.41 days; 95% CI, −0.51 to −0.32; P < .001). However, the rate of skin blisters was higher in ciNPWT (OR, 4.44; 95% CI, 2.24-8.79; P < .001).ConclusionAlthough skin blisters were more likely to develop in ciNPWT, the risks of wound complication, SSI, reoperation, and longer LOH decreased in ciNPWT compared with those in conventional dressings. This finding could alleviate the potential concerns regarding wound-related problems after THA and TKA.     

Does Productivity-Based Physician Compensation Affect Surgical Rates for Elective Arthroplasty Surgery?

BackgroundSurgeon compensation models could potentially influence the utilization of elective procedures. We assessed whether transitioning from salaried to a relative value unit (RVU) productivity-based physician compensation model changed the surgical rate and patient selection in elective total hip and knee arthroplasty (THA and TKA) procedures.MethodsOur institution transitioned from salaried to RVU productivity-based reimbursement in July 2016. We performed a retrospective analysis on patients undergoing primary THA and TKA from July 2014 to July 2018 before and after the transition (salary period n = 820; RVU period n = 1188). Beta regression was used to determine the reimbursement structure as a predictor of surgery. The surgical rate was defined as the number of primary THA and TKA procedures per reimbursement period divided by all arthroplasty and osteoarthritis outpatient clinic encounters.ResultsThere was a surgical rate of 15.8% (95% confidence interval [CI] 13.8%-17.8%) THA and 16.7% (95% CI 15.1%-18.1%) TKA procedures during RVU reimbursement compared to 11.1% (95% CI 9.8%-12.8%) THA and 11.7% (95% CI 10.5%-12.8%) TKA procedures during the salaried period (P < .001). The adjusted odds of undergoing a THA or TKA procedure increased in the RVU compared to the salaried model (THA odds ratio 1.48, 95% CI 1.43-1.53; TKA odds ratio 1.50, 95% CI 1.46-1.55; P < .001). There were no significant differences in patient age, gender, race, body mass index, or Charlson Comorbidity Index in salaried vs RVU productivity periods (P > .05 for all covariates).ConclusionsProductivity-based physician compensation may encourage higher rates of elective arthroplasty procedures without broadening patient selection.