Fixation or Revision for Periprosthetic Fractures: Epidemiology, New Trends, and Projections in the United States.

BACKGROUND: Periprosthetic fractures can be devastating complications after total joint arthroplasty (TJA). The management of periprosthetic fractures is complex, spanning expertise in arthroplasty and trauma. The purpose of this study was to examine and project trends in the operative treatment of periprosthetic fractures in the United States. METHODS: A large, public and private payer database was queried to capture all International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for periprosthetic femoral and tibial fractures. Statistical models were created to assess trends in treatment for periprosthetic fractures and to predict future surgical rates. An alpha value of 0.05 was used to assess significance. A Bonferroni correction was applied where applicable to account for multiple comparisons. RESULTS: In this study, from 2016 to 2021, 121,298 patients underwent surgical treatment for periprosthetic fractures. There was a significant increase in the total number of periprosthetic fractures. The incidence of periprosthetic hip fractures rose by 38% and that for periprosthetic knee fractures rose by 73%. The number of periprosthetic fractures is predicted to rise 212% from 2016 to 2032. There was a relative increase in open reduction and internal fixation (ORIF) compared with revision arthroplasty for both periprosthetic hip fractures and periprosthetic knee fractures. CONCLUSIONS: Periprosthetic fractures are anticipated to impose a substantial health-care burden in the coming decades. Periprosthetic knee fractures are predominantly treated with ORIF rather than revision total knee arthroplasty (TKA), whereas periprosthetic hip fractures are predominantly treated with revision total hip arthroplasty (THA) rather than ORIF. Both periprosthetic knee fractures and periprosthetic hip fractures demonstrated increasing trends in this study. The proportion of periprosthetic hip fractures treated with ORIF relative to revision THA has been increasing. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

No Difference in Perioperative Complications for Bilateral Total Knee Arthroplasty Staged at 1 Week Compared With Delayed Staging.

INTRODUCTION: Controversy exists regarding the safety of simultaneous bilateral total knee arthroplasty (TKA) versus two TKA procedures staged months apart in patients with bilateral knee arthritis. Here, we investigated a third option: bilateral TKA staged 1 week apart. In this study, we examined the rate of complications in patients undergoing bilateral TKA staged at 1 week compared with longer time intervals. METHODS: A retrospective review of 351 consecutive patients undergoing bilateral TKA at our institution was conducted. Patients underwent a 1-week staged bilateral procedure with planned interim transfer to a subacute rehabilitation facility (short-staged) or two separate unilateral TKA procedures within 1 year (long-staged). Binary logistic regression was used to compare outcomes while controlling for year of surgery, patient age, body mass index, and Charlson Comorbidity Index. RESULTS: Two hundred four short-staged and 147 long-staged bilateral TKA patients were included. The average interval between procedures in long-staged patients was 200.9 ± 95.9 days. Patients undergoing short-staged TKA had a higher Charlson Comorbidity Index (3.0 ± 1.5 versus 2.6 ± 1.5, P = 0.017) with no difference in preoperative hemoglobin ( P = 0.285) or body mass index ( P = 0.486). Regression analysis demonstrated that short-staged patients had a higher likelihood of requiring a blood transfusion (odds ratio 4.015, P = 0.005) but were less likely to return to the emergency department within 90 days (odds ratio 0.247, P = 0.001). No difference was observed in short-term complications ( P = 0.100), 90-day readmissions ( P = 0.250), or 1-year complications ( P = 0.418) between the groups. CONCLUSION: Bilateral TKA staged at a 1-week interval is safe with a comparable complication rate with delayed staged TKA, but allows for a faster total recovery time. LEVEL OF EVIDENCE: Level III.

Profound Impact of Insurance Payor and Socioeconomic Status in Total Hip Arthroplasty Outcomes: Results From a High Volume Tertiary Care Center.

BACKGROUND: Dual eligible Medicare/Medicaid patients undergoing total hip arthroplasty (THA) have worse outcomes compared to other insurance payors. Prior literature fails to control for the heterogeneity of care provided amongst a large cohort of hospitals and surgeons as well as differences in patient populations treated. This study compares dual eligible THA patients and Medicaid and Medicare only THA patients at a single high volume tertiary center. METHODS: We retrospectively reviewed patients who underwent THA for aseptic osteoarthritis of the hip over a three-year period with either Medicaid or Medicare insurance. 3,329 THA patients were included, of which 439 were Medicaid payor, 182 were dual eligible, and 2,708 were Medicare payor. Groups were compared using appropriate tests for direct comparisons and regression analysis. RESULTS: Dual eligible patients were less likely to be white and married, and were more likely to be current smokers and have COPD, liver disease, renal disease, and human immunodeficiency virus (HIV) compared to Medicare patients. These patients also had a lower age-adjusted Charleson Comorbidity Index when compared to Medicare patients (2.4 vs 3.4, P < .001). When controlling for smoking status, age, BMI and major medical comorbidities, dual eligible and Medicaid patients had increased length of stay (LOS) (0.58, 0.66 days, P < .001), higher risk of discharge to subacute rehabilitation (RR 1.97, 3.19, P < .001), and dual eligible patients more often returned to the ED within 90 days (RR 2.74, P < .001) compared to Medicare patients. CONCLUSION: This study supports the implementation of socioeconomic risk stratification efforts to properly evaluate value-based healthcare metrics in total hip arthroplasty patients.

Does Dual-Eligible Medicare/Medicaid Insurance Status as a Surrogate for Socioeconomic Status Compromise Total Knee Arthroplasty Outcomes?

BACKGROUND: Medicare/Medicaid dual-eligible patients who undergo primary total knee arthroplasty (TKA) demonstrate poor outcomes when compared to patients with other payers. We compare Medicare/Medicaid dual-eligible patients vs Medicare and Medicaid only patients at a single hospital center. METHODS: All patients who underwent TKA for aseptic arthritis between August 9, 2016 and December 30, 2020 with either Medicare or Medicaid insurance were retrospectively reviewed. 4599 consecutive TKA (3749 Medicare, 286 Medicare/Medicaid dual eligibility, and 564 Medicaid) were included. Groups were compared using appropriate tests for direct comparisons and regression analysis. RESULTS: Patients with dual eligibility and Medicaid insurance were less likely to be white and married, more likely to be female and current smokers, and more likely to have COPD, mild liver disease, diabetes mellitus, malignancy, and HIV/AIDS, but had a lower age-adjusted Charleson Comorbidity Index when compared to Medicare patients. When controlling for smoking status and medical comorbidities, patients with dual eligibility and Medicaid insurance stayed in the hospital 0.64 and 0.39 additional days (P < .001), respectively, were more likely to be discharged to subacute rehab (RR 2.01, 1.49, P < .001) and acute rehab (RR 2.22, 2.46, P = .007, < .001), and were 2.14 and 1.73 times more likely to return to the ED within 90 days (P < .001) compared to Medicare patients. CONCLUSION: Value-based healthcare may disincentivize treating patients with low socioeconomic status, represented by Medicaid and dual-eligible insurance status, by their association with increased postoperative healthcare utilization, and less risky patients may be prioritized.

Subspecialty Fellowship Training Is Not Associated With Better Outcomes in Fixation of Low-Energy Femoral Neck Fractures-An Analysis of the Fixation Using Alternative Implants for the Treatment of Hip Fractures Database.

OBJECTIVES: To compare risk of reoperation for femoral neck fracture patients undergoing fixation with cancellous screws (CSs) or sliding hip screws based on surgeon fellowship (trauma-fellowship-trained vs. non-trauma-fellowship-trained). DESIGN: Retrospective review of Fixation using Alternative Implants for the Treatment of Hip fractures data. SETTING: Eighty-one centers across 8 countries. PATIENTS/PARTICIPANTS: Eight hundred nineteen patients ≥50 years old with low-energy hip fractures requiring surgical fixation. INTERVENTION: Patients were randomized to CS or sliding hip screw group in the initial dataset. MAIN OUTCOME MEASUREMENTS: The primary outcome was risk of reoperation. Secondary outcomes included death, serious adverse events, radiographic healing, discharge disposition, and use of ambulatory devices postoperatively. RESULTS: There was no difference in risk of reoperation between the 2 surgeon groups (P > 0.05). Patients treated by orthopaedic trauma surgeons were more likely to be overweight/obese and have major medical comorbidities (P < 0.05). There was a higher risk of serious adverse events, higher likelihood of radiographic healing, and higher odds of discharge to a facility for patients treated by trauma-fellowship-trained surgeons (P < 0.05). CONCLUSIONS: Based on these data, risk of reoperation for low-energy femoral neck fracture fixation is equivalent regardless of fellowship training. The higher likelihood of radiographic healing noted in the trauma-trained group does not seem to have a major clinical implication because it did not affect risk of reoperation between the 2 groups. Patient-specific factors present preinjury, such as body habitus and medical comorbidities, may account for the lower odds of discharge to home and higher risk of postoperative medical complications for patients treated by orthopaedic trauma surgeons. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

COVID-19 as a disruptor: innovation and value in a national virtual fracture conference.

OBJECTIVES: The aim of this study was to determine the educational value of a national virtual fracture conference implemented during the COVID-19 disruption of resident education. DESIGN: Survey study. SETTING: National virtual conference administered by the Orthopaedic Trauma Association. PARTICIPANTS: Attendees of virtual fracture conference. INTERVENTION: Participation at a national virtual fracture conference. MAIN OUTCOME MEASURE: Surveys of perception of quality and value of virtual conferences relative to in-person conferences. RESULTS: Ninety-six percent of participants rated the virtual fracture conference as similar or improved educational quality relative to conventional in-person fracture conference. Participants also felt they learned as much (35%) or more (57%) at each virtual fracture conference compared to the amount learned in-person. The quality of interpersonal interactions at both the resident-faculty level and faculty-faculty level was also perceived to be overall superior to those at participants' own institutions. Learners felt they were more likely to engage the primary literature as well. Overall, 100% of participants were likely to recommend virtual conference to their colleagues and 100% recommended continuing this conference even after COVID-19 issues resolve. CONCLUSIONS: We found that learners find significant educational value in a national virtual fracture conference compared to in-person fracture conferences at their own institution. COVID-19 has proven to be a disruptor not only in health care but in medical education as well, accelerating our adoption of innovative and novel resident didactics. LEVEL OF EVIDENCE: Therapeutic Level III.

Who Did the Arthroplasty? Hip Fracture Surgery Reoperation Rates are Not Affected by Type of Training-An Analysis of the HEALTH Database.

OBJECTIVES: This study compares outcomes for patients with displaced femoral neck fractures undergoing hemiarthroplasty (HA) or total hip arthroplasty (THA) by surgeons of different fellowship training. DESIGN: Retrospective review of HEALTH trial data. SETTING: Eighty clinical sites across 10 countries. PATIENTS/PARTICIPANTS: One thousand four hundred forty-one patients ≥50 years with low-energy hip fractures requiring surgical intervention. INTERVENTION: Patients were randomized to either HA or THA groups in the initial data set. Surgeons' fellowship training was ascertained retrospectively, and outcomes were compared. MAIN OUTCOME MEASUREMENTS: The main outcome was an unplanned secondary procedure at 24 months. Secondary outcomes included death, serious adverse events, prosthetic joint infection (PJI), dislocation, discharge disposition, and use of ambulatory devices postoperatively. RESULTS: There was a significantly higher risk of PJI in patients treated by surgeons without fellowship training in arthroplasty (P = 0.01), surgeons with unknown fellowship training (P = 0.03), and surgeons with no fellowship training (P = 0.02) than those treated by an arthroplasty-trained surgeon. There were significantly higher odds of being discharged to a facility rather than home in patients who underwent surgery by a surgeon with no fellowship training compared with arthroplasty-fellowship-trained surgeons (P = 0.03). CONCLUSIONS: Arthroplasty for hip fracture can be performed by all orthopaedic surgeons with equivalent reoperation rates. Infection prevention strategies and use of "care pathways" by arthroplasty-fellowship-trained surgeons may account for the lower risk of PJI and higher rate of discharge to home. The authors advocate for the use of evidence-based infection prevention initiatives and standardized care pathways in this patient population. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Higher Rate of Early Revision Following Primary Total Knee Arthroplasty in Patients Under Age 55: A Cautionary Tale.

BACKGROUND: There has been an increased number of total knee arthroplasties (TKAs) performed in young and active patients. Although improved materials have decreased the likelihood of early catastrophic wear, concerns remain with the performance and survivorship of TKA implants in this patient population. The purpose this study is to evaluate perioperative complications, patient-reported outcomes, and implant survivorship of TKAs performed in patients under age 55. METHODS: We retrospectively reviewed 4259 primary TKAs performed over a 4-year period. There were 741 TKAs in patients under age 55. The primary outcome of interest was rate of revision at 30 days, 1, 2, and 5-year time points. Secondary outcomes included postoperative transfusion rate, length of stay, rate of deep vein thrombosis/pulmonary embolism, need for manipulation under anesthesia, readmission and reoperation within 30 days, as well as patient-reported outcomes. RESULTS: There were 3518 patients over 55 years and 741 patients under 55 years. Overall, 175 patients required revision (4.1%). Patients under 55 years had significantly higher cumulative revision rate at 1 (3.4% vs 1.8%, P < .001), 2 (5.0% vs 2.4%, P < .001), and 5 years (7.3% vs 3.7%, P < .001). Patients under 55 years had a higher rate of early reoperation. Patients over 55 years required more transfusions and suffered a higher rate of early deep vein thrombosis. Patients over 55 years had significantly greater improvements in Patient Reported Outcome Measurement Information System Global 10 Physical scores at 6 months postoperatively compared to patients under 55 years. CONCLUSIONS: Despite improvements in TKA implants, young and active patients remained at higher risk of early revision compared to older patients. The data should be used to counsel young prospective TKA patients about the early risk of reoperation and non-wear-related complications.

Intrapleural Penetration of a Clavicle Fracture: An Indication for Operative Fixation.

INTRODUCTION: Clavicle fractures are common injuries treated by orthopedic surgeons, with most injuries managed nonoperatively. Operative fixation of clavicle fractures is indicated in specific clinical scenarios such as open injuries, ipsilateral shoulder trauma, or fractures with associated neurovasculature compromise. Operative fixation is not widely accepted for closed injuries and is typically reserved for instances of failed closed treatment with resultant nonunion or delayed union. Among the complications associated with clavicle fractures, pneumothorax has not been commonly reported. We report a case of a severely displaced clavicle fracture requiring operative repair through plate fixation to achieve union of the fracture as well as resolve the pneumothorax. CASE REPORT: A 22-year-old intoxicated male with no past medical history was admitted to the trauma bay in stable condition after being involved in a motor vehicle accident. On the primary survey, the patient was noted to be tachypneic with decreased breath sounds over his right hemithorax. Radiographic studies of his chest demonstrated a right proximal third clavicle fracture with inferior displacement with associated partial pneumothorax; the patient was also noted to have a right femoral shaft fracture. Neurovascular examinations of his extremities were normal. A chest thoracostomy tube was inserted and placed under suction. Computerized tomography studies later revealed that the fractured clavicle had penetrated the pleura and caused the partial lung collapse. The patient was initially placed in a sling and underwent intramedullary nailing of his femur on the day of presentation. Given the severe displacement of his clavicle fracture into the lung tissue resulting in pneumothorax, there was significant concern for nonunion and lack of resolution of the pneumothorax. 2 days after stabilization of his right femur fracture, the patient underwent open reduction with internal fixation of his right clavicle. Follow-up radiographs showed a healed clavicle fracture and resolved pneumothorax. CONCLUSION: Closed clavicle fractures typically heal uneventfully. Low energy, minimally displaced clavicle fractures can be managed nonoperatively, but high energy, significantly displaced injuries may require operative repair. Specifically, if these injuries result in pneumothorax, physicians shoulder consider operative repair for both treatment of the bony defect as well resulting pneumothorax.