The cost-effectiveness of osteoporosis medications for preventing periprosthetic fractures following femoral neck fracture indicated hip arthroplasty: a break-even analysis.

Osteoporosis treatment following arthroplasty for femoral neck fracture (FNF) is associated with lower rates of periprosthetic fracture (PPF). Our study evaluated the economic viability of treatment in patients following arthroplasty and demonstrates that treatment with oral bisphosphonates can be cost-effective in preventing PPF. INTRODUCTION: Osteoporosis treatment following arthroplasty for femoral neck fracture (FNF) is associated with lower rates of periprosthetic fracture (PPF). Although cost-effective in reducing the rate of secondary fragility fracture, the economic viability of osteoporosis treatment in preventing PPF has not been evaluated. Therefore, the purpose of this study is to use a break-even analysis to determine whether and which current osteoporosis medications are cost-effective in preventing PPF following arthroplasty for FNFs. METHODS: Three-year average cost of osteoporosis medication (oral bisphosphonates, estrogen hormonal therapy, intravenous (IV) bisphosphonates, denosumab, teriparatide, and abaloparatide), costs of PPF care, and PPF rates in patients who underwent hip arthroplasty for FNFs without osteoporosis treatment were used to perform a break-even analysis. The absolute risk reduction (ARR) related to osteoporosis treatment and sensitivity analyses were used to evaluate the cost-effectiveness of this intervention and break-even PPF rates. RESULTS: Oral bisphosphonate therapy following arthroplasty for hip fractures would be economically justified if it prevents one out of 56 PPFs (ARR, 1.8%). Given the current cost and incidence of PPF, overall treatment can only be economically viable for PPF prophylaxis if the 3-year costs of these agents are less than $1500. CONCLUSION: The utilization of lower cost osteoporosis medications such as oral bisphosphonates and estrogen hormonal therapy as PPF prophylaxis in this patient population would be economically viable if they reduce the PPF rate by 1.8% and 1.5%, respectively. For IV bisphosphonates and newer agents to be economically viable as PPF prophylaxis in the USA, their costs need to be significantly reduced.

Osteoporosis and Total Knee Arthroplasty: Higher 5-Year Implant-Related Complications.

BACKGROUND: The risk of revision surgery in patients who have osteoporosis after total knee arthroplasty (TKA) is understudied. Our aim was to compare the 5-year cumulative risk of revision surgery after TKA in patients who have preoperative osteoporosis. METHODS: A national administrative claims database was queried for patients undergoing primary TKA from 2010 to 2021. There were 418,054 patients included, and 41,760 (10%) had osteoporosis. The 5-year incidence of revision surgery was examined for all-causes, periprosthetic fracture (PPF), aseptic loosening, and periprosthetic joint infection (PJI). A multivariable analysis was conducted using Cox proportional hazards models. Hazards ratios (HRs) were reported with 95% confidence intervals (CIs). RESULTS: The 5-year rate of all-cause revision surgery was higher for patients who had osteoporosis (HR 1.1, 95% CI: 1.0 to 1.2), however, the highest risk of revision surgery was seen for PPF (HR 1.8, 95% CI: 1.6 to 2.1). Patients who had osteoporosis also had elevated risk of revision surgery for PJI (HR 1.2, 95% CI: 1.1 to 1.3) and aseptic loosening (HR 1.2, 95% CI: 1.1 to 1.3). Osteoporosis was independently associated with PJI and aseptic loosening at a higher rate in obese patients. CONCLUSIONS: In unadjusted survival analysis, those who had osteoporosis have a marginally lower risk of all-cause revision surgery. However, after controlling for age, sex and comorbidities, patients who had osteoporosis have a nearly 2-fold increased risk of 5-year revision for PPF after TKA, and mildly increased risk of revision for all causes, aseptic loosening, and PJI. Obesity may also modulate this association. Future studies should determine the extent to which treatment of osteoporosis modifies these postoperative outcomes.

Risk Factors Associated With Quadriceps Tendon Extensor Mechanism Disruption Following Total Knee Arthroplasty.

BACKGROUND: Quadriceps tendon extensor mechanism disruption is an infrequent but devastating complication after total knee arthroplasty (TKA). Our knowledge of specific risk factors for this complication is limited by the current literature. Thus, this study aimed to identify potential risk factors for quadriceps tendon extensor mechanism disruption following TKA. METHODS: A retrospective cohort analysis was performed using the PearlDiver Administrative Claims Database. Patients undergoing TKA without a prior history of quadriceps tendon extensor mechanism disruption were identified. Quadriceps tendon extensor mechanism disruption included rupture of the quadriceps tendon, patellar tendon, or fracture of the patella. Patients who had a minimum of 5 years of follow-up after TKA were included. A total of 126,819 patients were included. Among them, 517 cases of quadriceps tendon extensor mechanism disruption occurred (incidence 0.41%). Hypothesized risk factors were compared between those who had postoperative quadriceps tendon extensor mechanism disruption and those who did not. RESULTS: On multivariate analysis, increased Charlson Comorbidity Index (odds ratio (OR): 1.10, 95% confidence interval (CI) [1.07 to 1.13]; P < .001), obesity (OR: 1.49, 95% CI [1.24 to 1.79]; P < .001), and fluoroquinolone use any time after TKA (OR: 1.24, 95% CI [1.01 to 1.52]; P = .036) were significantly associated with quadriceps tendon extensor mechanism disruption. CONCLUSIONS: Our study identified the incidence of quadriceps tendon extensor mechanism disruption following TKA as 0.41%. Identified risk factors for quadriceps tendon extensor mechanism disruption after TKA include an increased Charlson Comorbidity Index, obesity, and use of fluoroquinolones postoperatively.

Trends in Venous Thromboembolism and Chemoprophylaxis Utilization in Elective Total Knee Arthroplasty From 2011 to 2020.

BACKGROUND: Venous thromboembolism (VTE) is a feared complication of joint arthroplasty, leading to recent clinical practice guidelines aimed at VTE prevention and prophylaxis. However, limited studies have examined national changes in practice regarding chemoprophylaxis and the resultant changes in VTE rates. The purpose of this study was to identify: (1) the temporal trends in thrombotic complications; and (2) changes in chemoprophylaxis utilization in patients undergoing elective total knee arthroplasty (TKA). METHODS: A retrospective study was conducted using a large all-payer claims dataset. Patients who underwent osteoarthritis-indicated TKA between 2011 and 2020 were identified. Annual rates of VTE, including deep vein thrombosis and pulmonary embolism, within 90 days of TKA were determined. Utilization patterns for postoperative aspirin and anticoagulant medications were observed. Temporal trends were analyzed with linear regression and the calculation of the cumulative annual growth rate. Multivariable logistic regression was conducted to account for the effects of age and comorbidities. RESULTS: A total of 1,263,351 TKA patients were identified between 2011 and 2020. There were significant reductions in VTE rates (2.9% in 2011 to 1.8% in 2020), deep vein thrombosis rates (2.0% in 2011 to 1.3% in 2020), and pulmonary embolism rates (1.1% in 2011 to 0.6% in 2020). Postoperative utilization of aspirin increased from 5.9% in 2011 to 53.2% in 2020, whereas utilization of anticoagulants decreased from 94.1% in 2011 to 46.8% in 2020. Among anticoagulants, direct factor Xa inhibitors had the greatest increase in utilization (4.6 to 69.7%). The average reimbursement associated with VTE after TKA decreased from $18,061 in 2011 to $7,835 in 2020. CONCLUSIONS: The incidence rate and economic burden of VTE after TKA have significantly declined since 2011. There has been a trend toward increased aspirin and direct oral anticoagulant utilization for postoperative chemoprophylaxis. LEVEL OF EVIDENCE: Level III.

Hydroxyapatite-Coated Femoral Stems in Primary Total Hip Arthroplasty: An Updated Meta-Analysis.

BACKGROUND: Most primary total hip arthroplasties (THAs) performed in the United States utilize cementless fixation with porous or hydroxyapatite (HA) coating. A previous meta-analysis comparing HA-coated versus non-HA-coated stems in primary THA published in 2013 found no significant difference between the 2. However, an updated analysis of the current literature is needed to assess the potential benefit of HA-coated stems in primary THA. METHODS: Various libraries were searched through May 2022 according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Studies included were randomized controlled trials comparing HA-coated femoral stems to non-HA-coated stems in primary THA. Outcomes included Harris Hip Score (HHS), endosteal bone formation, radiolucent lines, linear wear rate, revision for aseptic loosening, thigh pain, and heterotopic ossification. RESULTS: There were significantly fewer revisions for aseptic loosening (P = .004) and decreased postoperative thigh pain (P = .03) for patients who have with HA-coated stems. There was no significant difference in HHS (P = .20), endosteal bone formation (P = .96), radiolucent lines (P = .75), linear wear rate (P = .41), or heterotopic ossification (P = .71) between HA-coated and non-HA-coated stems. CONCLUSION: We found that HA-coated femoral stems in primary THA led to significantly fewer stem revisions for aseptic loosening and less postoperative thigh pain compared to non-HA-coated stems. These findings suggest HA-coated femoral stems should be preferred over non-HA-coated femoral stems in primary THA.

Impact of Reporting Bias, Conflict of Interest, and Funding Sources on Quality of Orthopaedic Research.

BACKGROUND: Influence of factors like reporting outcomes, conflicts of interest, and funding sources on study outcomes, particularly positive outcomes in orthopedics, remains underexplored. As transparency of partnerships in orthopaedic surgery through conflicts of interest statements has increased over the years, there has been a lack of focus on the value of these partnerships in influencing study outcomes. We aimed to investigate the associations between reporting outcomes, conflicts of interest, and sources of funding on study outcomes. METHODS: We reviewed articles published in 1 year in The Journal of Bone and Joint Surgery, The American Journal of Sports Medicine, and The Journal of Arthroplasty. The abstracts were examined for appropriate inclusion, while the authors' names, academic degrees, funding disclosures, and departmental and institutional affiliations were redacted. There were a total of 1,351 publications reviewed from January 1, 2021 to December 31, 2021. RESULTS: A significant association was found between positive outcomes and reported conflicts of interest (75% versus 25%, P < .001). Likewise, conflicts of interest showed significant association with industry-sponsored studies (88% versus 12%, P < .001) and evidence level > II (72% versus 28%, P < .001). Industry-sponsored research accounted for the highest percentage of studies involving a conflict of interest (88%) and level I studies (12%). CONCLUSIONS: Conflicts of interest are significantly associated with positive outcomes in orthopaedics. Sponsored studies were more inclined to have conflicts of interest and accounted for the majority of level I studies.

Osteoporotic Patients Undergoing Total Hip Arthroplasty Have a Similar 5-Year Cumulative Incidence Rate of Periprosthetic Fracture Regardless of Cemented Versus Cementless Femoral Stem Fixation.

BACKGROUND: In osteoporotic patients, surgeons may utilize cemented femoral fixation to minimize risk of fracture. The purpose of this study was to compare 5-year implant survivability in patients who have osteoporosis who underwent elective total hip arthroplasty (THA) with cementless versus cemented fixation. METHODS: A retrospective analysis of patients who have osteoporosis undergoing THA with either cemented or cementless femoral fixation was conducted using a national administrative claims database. Of the 18,431 identified THA patients who have osteoporosis, 15,867 (86.1%) underwent cementless fixation. The primary outcome was a comparison of the 5-year cumulative incidences of aseptic revision, mechanical loosening, and periprosthetic fracture (PPF). Kaplan-Meier and Multivariable Cox Proportional Hazard Ratio analyses were used, controlling for femoral fixation method, age, sex, a comorbidity scale, use of osteoporosis medication, and important comorbidity. RESULTS: There was no difference in aseptic revision (Hazard's Ratio (HR): 1.13; 95% Confidence Interval (CI): 0.79 to 1.62; P value: .500) and PPF (HR: 0.96; 95% CI: 0.64 to 1.44; P value: .858) within 5 years of THA between fixation cohorts. However, patients who had cemented fixation were more likely to suffer mechanical loosening with 5 years post-THA (HR: 1.79; 95% CI: 1.17 to 2.71; P-value: .007). CONCLUSIONS: We found a similar 5-year rate of PPF when comparing patients who underwent cementless versus cemented femoral fixation for elective THA regardless of preoperative diagnosis of osteoporosis. While existing registry data support the use of cemented fixation in elderly patients, a more thorough understanding of the interplay between age, osteoporosis, and implant design is needed to delineate in whom cemented fixation is most warranted for PPF prevention.

10-Year Cumulative Incidence and Indications for Revision Total Joint Arthroplasty for Patients Who Have Ehlers-Danlos Syndrome.

BACKGROUND: Long-term complications following total joint arthroplasty are not well established for patients who have Ehlers-Danlos syndrome (EDS), a group of connective tissue disorders. This study compared 10-year incidence of revision surgery after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in patients who have and do not have EDS. METHODS: A retrospective cohort analysis was conducted using a national all-payer claims database from 2010 to 2021 to identify patients who underwent primary TKA or THA. Patients who had and did not have EDS were propensity score-matched by age, sex, and a comorbidity index. Kaplan-Meier analyses and Cox proportional hazard models were used to determine the cumulative incidence and risks of revision experienced by patients who have and do not have EDS. RESULTS: The EDS patients who underwent TKA had a higher risk of all-cause revision (hazard ratio [HR]: 1.50, 95% confidence interval [95% CI]: 1.09 to 2.07, P < .014) and risk of revision due to instability (HR = 2.49, 95% CI: 1.37 to 4.52, P < .003). The EDS patients who underwent THA had a higher risk of all-cause revision (HR = 2.32, 95% CI: 1.47 to 3.65, P < .001), revision due to instability (HR = 4.26, 95% CI: 2.17 to 8.36, P < .001), and mechanical loosening (HR = 3.63, 95% CI: 2.05 to 6.44, P < .001). CONCLUSIONS: Patients who had EDS were found to have a higher incidence of revision within 10 years of undergoing TKA and THA compared to matched controls, especially for instability. Patients who have EDS should be counseled accordingly. Surgical technique and implant selection should include consideration for increased constraint in TKA and larger femoral heads or dual mobility articulations for THA.

Trends in Extended Oral Antibiotic Prophylaxis Utilization Following Primary and Revision Total Hip Arthroplasty From 2010 to 2022.

BACKGROUND: In patients considered high-risk for infection, extended oral antibiotic (EOA) prophylaxis has been demonstrated to reduce rates of prosthetic joint infection following total hip arthroplasty (THA). Although national guidelines regarding their use have not yet been created, the increase in literature surrounding EOA prophylaxis suggests a potential change in practice patterns. The purpose of this study was to investigate the trends in utilization of EOA prophylaxis following THA from 2010 to 2022 and identify prescription patterns. METHODS: A total of 646,059 primary THA and 51,879 aseptic revision THA patients were included in this study. Patients who underwent primary or aseptic revision THA between 2010 and 2022 were identified in a national administrative claims database. Rates and duration of EOA prescriptions were calculated. A secondary analysis examined rates of utilization across demographics, including patients considered high risk for infection. RESULTS: From 2010 to 2022, utilization of EOA increased by 366% and 298% following primary and revision THA, respectively. Of patients prescribed postoperative antibiotics, 30% and 59% were prescribed antibiotics for more than 7 days following primary and revision THA, respectively. Rates of utilization were similar between high-risk individuals and the general population. CONCLUSIONS: Rates of utilization of EOA prophylaxis after THA have increased significantly since 2010. As current trends demonstrate a wide variation in prescription patterns, including in length of antibiotic duration and in patient population prescribed, guidelines surrounding the use of EOA prophylaxis after THA are necessary to promote antibiotic stewardship while preventing rates of periprosthetic joint infection.

The Association Between Oral Bone Mineral Density-Reducing Medications and the Risk of 2-Year Implant-Related Complications Following Total Knee Arthroplasty.

BACKGROUND: Certain medications interfere with the bone remodeling process and may potentially increase the risk of complications after total knee arthroplasty (TKA). As patients undergoing TKA may be taking these bone mineral density (BMD)-reducing medications, it is unclear as to whether and which medications impact TKA outcomes. Therefore, the purpose of this study was to observe the impact of various BMD-reducing medications on 2-year implant-related complications following TKA. METHODS: A retrospective analysis of patients undergoing primary TKA was conducted using a national administrative claims database. Patients were identified if they were taking any known BMD-reducing medication and were compared to control patients. To control for confounders associated with taking multiple agents, multivariable logistic regression analyses were conducted for each 2-year outcome (all-cause revision, loosening-indicated revision, and periprosthetic fracture--indicated revision), with the output recorded as odds ratios (ORs). RESULTS: In our study, 502,927 of 1,276,209 TKA patients (39.4%) were taking at least one BMD-reducing medication perioperatively. On multivariable analysis, medications associated with a higher likelihood of 2-year all-cause revision included first- and second-generation antipsychotics (SGAs) (OR: 1.42 and 1.26, respectively), selective serotonin reuptake inhibitors (SSRIs) (OR: 1.14), glucocorticoids (1.13), and proton pump inhibitors (PPIs) (OR: 1.23) (P < .05 for all). Medications associated with a higher likelihood of 2-year periprosthetic fracture included SGAs (OR: 1.51), SSRIs (OR: 1.27), aromatase inhibitors (OR: 1.29), and PPIs (OR: 1.42) (P < .05 for all). CONCLUSIONS: Of the drug classes observed, the utilization of perioperative PPIs, SSRIs, glucocorticoids, first-generation antipsychotics, and SGAs was associated with the highest odds of all-cause revision. Our findings suggest a relationship between these medications and BMD-related complications; however, further studies should seek to determine the causality of these relationships.

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.

No Difference in Revision Rates up to 10 years Following Total Hip Arthroplasty in Patients Who Had Prior Bariatric Surgery When Compared to Patients Who Had Class III Obesity: A Propensity Matched Analysis.

BACKGROUND: There is no clear research showcasing bariatric surgery's (BS's) impact on long-term surgical complications following total hip arthroplasty (THA). Therefore, this study compared the 10-year cumulative incidence and risk of revision following THA in patients who underwent BS when compared to the general population and class III obesity patients who did not undergo BS. METHODS: Patients who underwent elective THA from 2010 to 2021 were identified using an all-payer claims database. Patients who underwent BS prior to THA were separately matched to a control of the general population and those who had class III obesity (body mass index ≥40) by age, sex, Charlson Comorbidity Index, and diabetes using a 1:4 ratio. Kaplan-Meier analyses generated 10-year cumulative incidence rates, and a Cox proportional hazard ratio (HR) model generated HRs and 95% confidence intervals (CIs). RESULTS: When compared to the general control, patients who have a history of BS had an elevated 10-year risk of all-cause revision (HR 1.31, 95% CI: 1.16 to 1.47, P < .001), prosthetic joint infection (HR: 1.62, CI: 1.30 to 2.04; P < .001), mechanical loosening (HR: 1.20, CI: 1.01 to 1.44; P = .040), and dislocation/instability (HR: 1.35, CI: 1.09 to 1.68; P = .007). There was no difference in the 10-year risk of all-cause revision or other indications for revision in the BS cohort compared to the matched class III obesity cohort (P = .142). CONCLUSIONS: Those who underwent BS before THA had comparable 10-year revision rates when compared to those who had class III obesity and higher rates compared to the general population. This suggests BS may not reduce the 10-year surgical risks associated with obesity when compared to a class III obese surgical population.

Trends in anti-osteoporotic medication utilization following fragility fracture in the USA from 2011 to 2019.

The purpose of this study was to determine whether there has been any change in osteoporosis treatment following primary fragility fractures and what agents were being given. The study found an overall low utilization rate with no difference in treatment utilization from 2011 to 2019. PURPOSE: The aim of this study is to describe trends in the utilization of anti-osteoporotic medication after fragility fracture, including changes in the specific types of medications prescribed. METHODS: Patients older than 65 with fragility fractures sustained from 2011 to 2019 were identified in the PearlDiver Patient Records Database. Osteoporosis treatment rate was defined as the rate at which patients were prescribed any of the fourteen most used anti-osteoporotic medications within 1 year of fragility fracture. Fragility fractures were subcategorized by type. Treatment of fragility fractures was further stratified by patient demographics (age and gender) and medication type. RESULTS: This study showed an overall osteoporosis treatment rate of 8.01%, with treatment rates of 6.87% following hip fractures, 6.71% following upper extremity fractures, and 14.38% following vertebral compression fractures (VCF). From 2011 to 2018, there was no change in the overall fragility fracture treatment rate (p = 0.32). Of the three fracture categories analyzed, only the treatment rate for VCFs increased (p = 0.048). Osteoporosis treatment in patients with VCF increased among patients 65-74 years old (p < 0.05) and male patients (p = 0.013). Treatment in patients with upper extremity fractures increased among patients 70-74 years old (p = 0.038). Bisphosphonates were the most frequently prescribed class of medications. Bisphosphonates and denosumab increased in utilization (p = 0.049 and p < 0.001 respectively) while calcitonin utilization decreased (p < 0.001). CONCLUSION: Besides the overall low utilization rate of osteoporosis treatment in patients following fragility fractures, there has been no change in the treatment utilization rate within the past decade. More resources and interventions need to be enforced for all providers managing these patients if we are ever to address the osteoporosis epidemic.

The impact of prior fragility fractures on long-term periprosthetic fracture risk following total knee arthroplasty.

The study found that patients undergoing total knee arthroplasty with prior fragility fracture had increased risk of subsequent fragility fracture and periprosthetic fracture within 8 years postoperatively when compared to those without a prior history. However, these patients were not at increased risk for all-cause revision within this period. PURPOSE: The aim of this study was to characterize the association of prior FFs on long-term risk of secondary fragility fracture (FF), periprosthetic fracture (PPF), and revision TKA. METHODS: Patients at least 50 years of age who underwent elective TKA were identified in the PearlDiver Database. Patients were stratified based on whether they sustained a FF within 3 years prior to TKA (7410 patients) or not (712,954 patients). Demographics and comorbidities were collected. Kaplan Meier analysis was used to observe the cumulative incidence of all-cause revision, PPF, and secondary FF within 8 years of TKA. Cox Proportional hazard ratio analysis was used to statistically compare the risk. RESULTS: In total, 1.0% of patients had a FF within three years of TKA. Of these patients, only 22.6% and 10.9% had a coded diagnosis of osteoporosis and osteopenia, respectively, at time of TKA. The 8-year cumulative incidence of secondary FF and periprosthetic fracture was significantly higher in those with a prior FF (27.5% secondary FF and 1.9% PPF) when compared to those without (9.1% secondary FF and 0.7% PPF). After adjusting for covariates, patients with a recent FF had significantly higher risks of secondary FF (HR 2.73; p < 0.001) and periprosthetic fracture (HR 1.86; p < 0.001) than those without a recent FF. CONCLUSIONS: Recent FF before TKA is associated with increased risk for additional FF and PPF within 8 years following TKA. Surgeons should ensure appropriate management of fragility fracture is undertaken prior to TKA to minimize fracture risk, and if not, be vigilant to identify patients with prior FF or other bone health risk factors who may have undocumented osteoporosis.

Can Hip and Knee Arthroplasty Surgeons Help Address the Osteoporosis Epidemic?

BACKGROUND: Osteoporosis is a known, modifiable risk factor for lower extremity periprosthetic fractures. Unfortunately, a high percentage of patients at risk of osteoporosis who undergo THA or TKA do not receive routine screening and treatment for osteoporosis, but there is insufficient information determining the proportion of patients undergoing THA and TKA who should be screened and their implant-related complications. QUESTIONS/PURPOSES: (1) What proportion of patients in a large database who underwent THA or TKA met the criteria for osteoporosis screening? (2) What proportion of these patients received a dual-energy x-ray absorptiometry (DEXA) study before arthroplasty? (3) What was the 5-year cumulative incidence of fragility fracture or periprosthetic fracture after arthroplasty of those at high risk compared with those at low risk of osteoporosis? METHODS: Between January 2010 and October 2021, 710,097 and 1,353,218 patients who underwent THA and TKA, respectively, were captured in the Mariner dataset of the PearlDiver database. We used this dataset because it longitudinally tracks patients across a variety of insurance providers throughout the United States to provide generalizable data. Patients at least 50 years old with at least 2 years of follow-up were included, and patients with a diagnosis of malignancy and fracture-indicated total joint arthroplasty were excluded. Based on this initial criterion, 60% (425,005) of THAs and 66% (897,664) of TKAs were eligible. A further 11% (44,739) of THAs and 11% (102,463) of TKAs were excluded because of a prior diagnosis of or treatment for osteoporosis, leaving 54% (380,266) of THAs and 59% (795,201) of TKAs for analysis. Patients at high risk of osteoporosis were filtered using demographic and comorbidity information provided by the database and defined by national guidelines. The proportion of patients at high risk of osteoporosis who underwent osteoporosis screening via DEXA scan within 3 years was observed, and the 5-year cumulative incidence of periprosthetic fractures and fragility fracture was compared between the high-risk and low-risk cohorts. RESULTS: In total, 53% (201,450) and 55% (439,982) of patients who underwent THA and TKA, respectively, were considered at high risk of osteoporosis. Of these patients, 12% (24,898 of 201,450) and 13% (57,022 of 439,982) of patients who underwent THA and TKA, respectively, received a preoperative DEXA scan. Within 5 years, patients at high risk of osteoporosis undergoing THA and TKA had a higher cumulative incidence of fragility fractures (THA: HR 2.1 [95% CI 1.9 to 2.2]; TKA: HR 1.8 [95% CI 1.7 to 1.9]) and periprosthetic fractures (THA: HR 1.7 [95% CI 1.5 to 1.8]; TKA: HR 1.6 [95% CI 1.4 to 1.7]) than those at low risk (p < 0.001 for all). CONCLUSION: We attribute the higher rates of fragility and periprosthetic fractures in those at high risk compared with those at low risk to an occult diagnosis of osteoporosis. Hip and knee arthroplasty surgeons can help reduce the incidence and burden of these osteoporosis-related complications by initiating screening and subsequently referring patients to bone health specialists for treatment. Future studies might investigate the proportion of osteoporosis in patients at high risk of having the condition, develop and evaluate practical bone health screening and treatment algorithms for hip and knee arthroplasty surgeons, and observe the cost-effectiveness of implementing these algorithms. LEVEL OF EVIDENCE: Level III, therapeutic study.

Higher revision rates in patients with preoperative contralateral pes planovalgus deformity following total knee arthroplasty.

PURPOSE: The purpose of this study was to compare the incidence of revision in those with pes planovalgus deformity to those without using a large national database. Given the reciprocal changes in lower extremity alignment associated with planovalgus foot deformity, it has been suggested that patients with this deformity has worse outcomes following total knee arthroplasty (TKA). METHODS: A retrospective cohort analysis of patients undergoing elective TKA was conducted using the PearlDiver database. Patients were stratified into three cohorts: those without pes planovalgus, patients with ipsilateral or bilateral pes planovalgus relative to the TKA, and patients with contralateral pes planovalgus. Patients with prior foot reconstructive surgery were excluded. The cohorts were each matched to those without pes planovalgus. Bivariate analysis was performed comparing 90-day medical complications and 2- and 4-year revisions following TKA. An adjusted number needed to be exposed for one additional person to be harmed (NNEH) was calculated using the adjusted odds ratio (OR) and unexposed event rate. RESULTS: Following matched analysis, those with contralateral pes planovalgus had similar odds (OR 3.41; 95% CI 0.93-12.54; p = n.s.) for aseptic revision within 2 years but significantly higher odds (OR 3.35; 95% CI 1.08-10.41; p = 0.03) within 4 years when compared to those without a pes planovalgus deformity. Within 4 years, there was no significant difference in the incidence of aseptic revision (p = n.s.) in patients with ipsilateral/bilateral pes planovalgus. No patients in any cohort underwent septic revision within 4 years of TKA. CONCLUSION: This study found that patients with contralateral pes planovalgus deformity had higher odds of aseptic revision within 4 years following primary TKA in a national database, suggesting that the change in gait kinematics associated with this deformity could possibly be associated with increased revision rates. LEVEL OF EVIDENCE: Level III.

A Novel Method for Stratification of 30-Day Major Complication Risk Using Body Mass Index Thresholds for Patients Undergoing Total Knee Arthroplasty: A National Cohort of 443,157 Patients.

BACKGROUND: Many organizations have used pre-established body mass index (BMI) cut-offs to guide surgical decision-making. As there have been many improvements in patient optimization, surgical technique, and perioperative care over time, it is important to reassess these thresholds and contextualize them to total knee arthroplasty (TKA). The purpose of this study was to calculate data-driven BMI thresholds that predict significant differences in risk of 30-day major complications following TKA. METHODS: Patients who underwent primary TKA from 2010 to 2020 were identified in a national database. Stratum-specific likelihood ratio (SSLR) methodology was used to determine data-driven BMI thresholds at which the risk of 30-day major complications increased significantly. These BMI thresholds were tested using multivariable logistic regression analyses. A total of 443,157 patients were included, who had a mean age of 67 years (range, 18 to 89 years), mean BMI of 33 (range 19 to 59), and 11,766 (2.7%) patients had a 30-day major complication. RESULTS: SSLR analysis identified four BMI thresholds that were associated with significant differences in 30-day major complications: 19 to 33, 34 to 38, 39 to 50, and 51+. When compared to those who had a BMI between 19 and 33, the odds of sustaining a major complication sequentially and significantly increased by 1.1, 1.3, and 2.1 times (P < .05 for all) for the other thresholds. CONCLUSION: This study identified four data-driven BMI strata using SSLR analysis that were associated with significant differences in the risk of 30-day major complications following TKA. These strata can be used to guide shared decision-making in patients undergoing TKA.

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.

Higher 2-Year Cumulative Incidence of Mental Health Disorders Following Antibiotic Spacer Placement for Chronic Periprosthetic Joint Infection following Total Joint Arthroplasty.

BACKGROUND: The relationship of chronic periprosthetic joint infection (PJI) treatment on the development and relapse of mood disorders remains largely unreported. This study aims to compare the incidence of different mental health disorders following antibiotic spacer placement for chronic PJI when compared to aseptic revisions and primary procedures. METHODS: Patients who underwent antibiotic spacer for septic total hip and knee arthroplasty (PJI THA/TKA) were identified in the PearlDiver Database using Current Procedure Terminology (CPT) codes for hip and knee antibiotic spacers. Patients who underwent aseptic revision and primary-THA/TKA were also identified using CPT codes. The incidences of depressive, anxiety, bipolar, psychotic, and stress disorders were identified within 2 years following the index procedures via Kaplan-Meier Analysis. RESULTS: The risk of depressive (hazard ratio (HR): 1.5; P < .001) and stress (HR: 1.5; P < .001) disorders were significantly higher in those who underwent PJI-THA when compared to aseptic revision, with the added risk of bipolar when compared to primary THA. The risk of depressive (HR: 1.6; P < .001), stress (HR: 1.4; P < .001), bipolar (HR: 1.3; P < .001), and psychotic disorders (HR: 1.5; P = .003) were significantly higher in those who underwent PJI-TKA when compared to aseptic revision, with the added risk of anxiety when compared to primary TKA. CONCLUSION: Patients who undergo spacer placement for septic-THA/TKA have a disproportionately higher incidence of mental health disorders within 2 years following surgery when compared those undergoing aseptic revisions and primary procedures. Due to this higher risk, physicians should strongly consider collaborative care with psychiatrists or mental health professionals. LEVEL OF EVIDENCE: III.

Interval Time of at Least 6 Weeks Between Bilateral Total Knee Arthroplasties is Associated With Decreased Postoperative Complications.

BACKGROUND: Staged, bilateral total knee arthroplasty (TKA) has an increased risk of complications if the second procedure is performed before physiologic recovery from the first. The aims of this study were to 1) determine whether there is a time-dependent relationship between TKA staging and rates of revisions and complications and 2) identify data-driven time intervals that reduce risk of revisions and complications. METHODS: Data were collected from a national insurance database from 2015 to 2018. Staged intervals were initially assessed using fixed 6-week intervals. Stratum-specific likelihood ratio analyses were subsequently conducted to observe data-driven staging thresholds. Bivariate and multivariable regression analyses were conducted to determine the associations between the time intervals and 2-year rates of revision surgery and 90-day major complications. We included 25,527 patients undergoing staged bilateral TKA. RESULTS: In comparison to the shortest fixed time interval (1-6 weeks), as the staging interval increased the odds of 2-year all-cause revision and 90-day major complications significantly decreased (P < .05 for all). Stratum-specific likelihood ratio analysis identified 3 data-driven staging categories 1-5, 6-17, and 18-24 weeks that maximized the difference in both 2-year rates of revision and 90-day major complications. CONCLUSION: Our data showed a time-dependent relationship between the timing of TKA stages and complications. If staging is considered, a delayed interval of at least 6 weeks between procedures may significantly reduce revision and major complications. LEVEL OF EVIDENCE: Level III Therapeutic Study.