International trends in shoulder replacement: a meta-analysis from 11 public joint registers.

BACKGROUND AND PURPOSE: International variation exists in the types of shoulder replacement used for treatment of specific diseases. Implant choice continues to evolve without high-quality evidence. Our aim was to evaluate trends in incidence rates of shoulder replacement and assess any recent changes in practice between countries by using registry data. METHODS: Patient characteristics, indication and year of surgery, type of replacement, and collection methods of patient-reported outcomes (PROMs) was extracted from 11 public joint registries. Meta-analyses examined use of reverse total shoulder replacement (RTSR) for osteoarthritis, cuff tear arthropathy, and acute fracture; use of anatomical total shoulder replacement (TSR) for osteoarthritis; and use of humeral hemiarthroplasty for fracture. RESULTS: The annual growth rate of shoulder replacements performed is 6-15% (2011-2019). The use of RTSR has almost doubled (93%). RTSR is now universally performed for cuff tear arthropathy (97.3%, 95% confidence interval [CI] 96.0-98.1). Its use for avascular necrosis, trauma, and inflammatory arthropathy is increasing. The use of RTSR was similar (43.1%, CI 30.0-57.2) versus TSR (44.7%, CI 31.1-59.1) for osteoarthritis. The types of PROMs used, collection time points, and response rates lack standardization. COVID-19 had a varying inter-registry impact on incidence rates. CONCLUSION: The incidence of shoulder replacements has grown. Use of RTSR has increased for all disease indications despite limited high-quality evidence driving this change in indications outside of cuff arthropathy. Consequently, less variation is observed in international practice. Existing differences now relate to use of newer implant types and methodology of PROMs collection, which prevents international comparison and outcome analysis.

No change in reoperation rates despite shifting treatment trends: a population-based study of 4,070 proximal humeral fractures.

Background and purpose - Clear and acknowledged treatment algorithms for proximal humeral fractures (PHFs) are lacking. Nevertheless, a change in treatment trends, including a change towards more reversed shoulder arthroplasties (RSA), has been observed during recent years. We examined the effect of these changes on reoperation rates.Patients and methods - Between 2011 and 2017, 4,070 PHFs treated at Sahlgrenska University Hospital were registered prospectively in the Swedish Fracture Register (SFR) and followed up until 2019 (mean follow-up of 4.5 years). Data on all reoperations were gathered from the SFR and from medical records.Results - The majority of PHFs were treated non-surgically and the proportion increased slightly, but not statistically significantly, during the study period (from 76% to 79%). Of the surgically treated fractures, the proportion fixed with a plate decreased from 47% to 25%, while the use of RSA increased 9-fold (from 2.0% to 19%). 221 patients underwent 302 reoperations. For those primarily treated surgically, the reoperation rate was 17%. Among treatment modalities, plate fixation was associated with the highest reoperation rate (21%). Rate of reoperations remained constant during the study period, both for the entire study cohort and for the surgically treated patientsInterpretation - During the study period, treatment changes that are in accordance with recently published treatment recommendations were observed. However, these treatment changes did not affect the reoperation rate. Treatment with a plate, intramedullary nail, or hemiarthroplasty was associated with the highest reoperation rates. The fact that almost every 4th surgical procedure was a reoperation indicates a need for further improvement of modern treatment concepts for PHFs.

The incidence of shoulder arthroplasty: rise and future projections compared with hip and knee arthroplasty.

BACKGROUND: There remains a paucity of epidemiologic data from recent years on the incidence of shoulder arthroplasty. We aimed to examine the recent trends and predict future projections of hemiarthroplasty (HA), anatomic (aTSA), and reverse shoulder arthroplasty (RSA), as well as compare these predictions to those for total hip (THA) and knee arthroplasty (TKA). METHODS: The National Inpatient Sample was queried from 2011 to 2017 for HA, aTSA, and RSA, as well as TKA and THA. Linear and Poisson regression was performed to project annual procedural incidence and volume to the year 2025. RESULTS: Between 2011 and 2017, the number of primary shoulder arthroplasties increased by 103.7%. In particular, RSA increased by 191.3%, with 63,845 RSAs performed in 2017. All projection models demonstrated significant increases in shoulder arthroplasty volume and incidence from 2017 to 2025. By 2025, the linear model predicts that shoulder arthroplasty volume will increase by 67.2% to 174,810 procedures whereas the Poisson model predicts a 235.2% increase, to 350,558 procedures by 2025. These growth rate projections outpace those of THA and TKA. CONCLUSIONS: The number of shoulder arthroplasties has been increasing in recent years, largely because of the exponential increases in RSA. The overall incidence is increasing at a greater rate than TKA or THA, with projections continuing to rise over the next decade. These data and projections can be used by policy makers and hospitals to drive initiatives aimed at meeting these projected future demands.

Cemented versus uncemented hemi-arthroplasty for femoral neck fractures in elderly patients: A systematic review and meta-analysis of randomized controlled trials.

AIM: To compare the efficacy and safety of cemented and uncemented hemiarthroplasty in elderly patients with femoral neck fracture. MATERIALS AND METHODS: We searched PubMed, EMBASE, and Cochrane Library databases for published randomized clinical trials comparing cemented hemiarthroplasty with uncemented hemiarthroplasty in elderly patients with a femoral neck fracture. The search was not limited to language, time, or other factors. The quality of each study was assessed using the revised Jadad scale. Two researchers independently extracted data from all selected studies, including the following base line data: study period, fracture stage, number of patients, male female ratio, average age, and per-protocol (PP) or intent-to-treat (ITT), and the interest outcomes: the mortality at 12 months, operative time, hospital stay, common complications, prosthetic-related complications, blood loss and Harris Hip Score (HHS). Fixed-effects or random-effects models with mean differences and odds ratios were used to pool the continuous and dichotomous variables to determine heterogeneity of the included studies. RESULTS: A total of 8 studies involving 1577 hips (782 uncemented and 795 cemented) were included in this meta-analysis. The meta-analysis is indicated that the operation time of cemented hemiarthroplasty was longer than uncemented hemiarthroplasty and there was statistical significance between two groups (OR = -7.30, 95%CI, -13.13, -1.46; P = .01). However, there was no significant difference between the two methods of fixation in mortality at 12 months (OR = 1.22, 95%CI, 0.94-1.59; P = .14), hospital stay (OR = 0.26, 95%CI, -0.41, 0.93; P = .44), blood loss (OR = -17.94, 95%CI, -65.83, 29.95; P = .46), and HHS score. There were significant differences in the common complications of pulmonary embolism between the two groups, but there were no differences in the other five common complications. The results showed that uncemented hemiarthroplasty could reduce the incidence of pulmonary embolism after operation. Moreover, the outcomes of prosthetic-related complications showed that there were significant differences between the two groups in periprosthetic fracture (OR = 8.32, 95%CI, 3.85-17.98; P < .00001) and prosthetic subsidence and loosening (OR = 5.33, 95%CI, 2.18-13.00; P = .0002). CONCLUSIONS: Our study shows that uncemented prosthesis can shorten the operation time and reduce the incidence of pulmonary embolism, but it does not reduce mortality, blood loss, and hospital stay. Most importantly, the incidence of prosthetic-related complications was higher in uncemented patients.

Surgery trends for osteonecrosis of the femoral head: a fifteen-year multi-centre study in Japan.

PURPOSE: The most appropriate procedure and at what type and stage of osteonecrosis of the femoral head (ONFH) these procedures had been argued. We attempted to clarify the trend in surgical operations with respect to the age of patients, type classification, and stage of ONFH over a period of 15 years by using the multi-center sentinel monitoring system in Japan. METHODS: We evaluated the hips of 3844 patients using this system in three phases of every five  years from 2003 to 2017. We classified the surgical procedures as osteotomy (OT), hemiarthroplasty (Hemi), and total hip arthroplasty (THA). We assessed the trend in age, type classification, and stage of ONFH over three time periods; "early," and the "late." We calculated the proportion of surgeries for ONFH in each period. We used the Cochran-Armitage test to evaluate trends in proportion of two levels of characteristics across three time periods. RESULTS: The proportion of younger patients significantly decreased. The proportion of OT and Hemi decreased over time, while the proportion of THA increased. The proportion of patients with types C1 and C2 who underwent OT and Hemi decreased over time. In contrast, that of THA increased. The proportion of patients who underwent OT and Hemi significantly decreased; the proportion of patients who underwent THA significantly increased over time at all stages. CONCLUSIONS: In Japan, the younger patients underwent surgery for ONFH decreased. The patients who underwent OT and Hemi for ONFH decreased, while that of THA increased over time.

Risk analysis and clinical outcomes of intraoperative periprosthetic fractures: a retrospective study of 481 bipolar hemiarthroplasties.

BACKGROUND: Intraoperative periprosthetic fractures (IPF) are a well-described complication following hip hemiarthroplasty. Our aims were to identify risk factors that characterize IPF and to investigate postoperative mobility. METHODS: We retrospectively reviewed 481 bipolar hemiarthroplasties for displaced femoral neck fractures; of which, 421 (87.5%) were performed without cement, from January 2013 to March 2018. Data on the patients' demographics, comorbidities, femoral canal geometry (Dorr canal type, Canal Flare Index), surgeon's experience (junior vs. senior surgeon), and timing of surgery (daytime vs. on-call duty) were obtained. In patients with intraoperative fractures, further information was obtained. Patient mobility was assessed using matched-pair analysis. Mobility was classified according to the NHFD mobility score. The chi-square test, Fisher's exact test, and Fisher-Freeman-Halton exact test were used for comparison between categorical variables, while the Mann-Whitney U test was used for continuous variables. The data analysis was performed using SPSS. RESULTS: Of 481 procedures, 34 (7.1%) IPFs were encountered. The Dorr canal type C was identified as a significant risk factor (p = .004). Other risk factors included female sex (OR 2.30, 95% CI .872-6.079), stovepipe femur (OR 1.749, 95% CI .823-3.713), junior surgeon (OR 1.204, 95% CI .596-2.432), and on-call-duty surgery (OR 1.471, 95% CI .711-3.046), although none showed a significant difference. Of 34 IPFs, 25 (73.5%) were classified as Vancouver type A. The treatment of choice was cerclage wiring. Within the 12 matched pairs identified, the postoperative mobility was slightly worse for the IPF group (delta = .41). CONCLUSIONS: IPF is a serious complication with bipolar hemiarthroplasty. The identification of risk factors preoperatively, in particular femur shape, is crucial and should be incorporated into the decision-making process.

The impact of the reverse prosthesis on revision shoulder arthroplasty: analysis of a high-volume shoulder practice.

BACKGROUND: Since the approval of reverse shoulder arthroplasty (RSA) in 2004, the use of shoulder arthroplasty increased dramatically. Although the success of RSA in the revision setting has been demonstrated, there remains a paucity of studies examining the epidemiology of RSA in revision arthroplasty. This study describes trends of revision arthroplasty during the "era of the reverse," from 2005 through 2016. METHODS: In a multicenter retrospective analysis, we analyzed 274 revision shoulder arthroplasties converted to a RSA (n = 182), anatomic total shoulder arthroplasty (TSA, n = 68), or hemiarthroplasty (n = 24) from 2005 to 2016. Demographics, surgical indications, and types of prosthesis were analyzed. RESULTS: The number of revision arthroplasties increased over 12 years. From 2005 to 2010, TSA (33%) or hemiarthroplasty (16%) were used in similar rates as RSA (51%). From 2011 to 2016, there was a much higher incidence of revision arthroplasty with RSA (78%) compared with TSA (19%) or hemiarthroplasty (3%). Specifically, the number of RSAs increased in 2011 to 2016 compared with 2005 to 2010 in patients aged younger than 60 years, obese patients, patients with indications of glenoid loosening, and those with a diagnosis of diabetes mellitus or rheumatoid arthritis. CONCLUSIONS: The use of RSA for revision arthroplasty increased over the "era of the reverse" and became the majority by 2016. The reverse prosthesis has had expanding indications regarding both patient demographics and pathology. This study demonstrates the reverse prosthesis has had a similar and even more profound effect on revision shoulder arthroplasty than what has previously been well documented in the primary setting.

Trends in surgical treatment of femoral neck fractures in the elderly.

OBJECTIVE: To analyze recent demographic and medical billing trends in treatment of femoral neck fracture of American elderly patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was analyzed from 2006 to 2015, for patients aged 65 years and older, using the Current Procedural Terminology codes 27130, 27125, 27235, and 27236. Patient demographics, postoperative complications, and frequency of codes were compared and analyzed over time. Our sample had 17,122 elderly patients, in that, 70% were female, mean age of 80.1 years (standard deviation±6.6 years). RESULTS: The number of cases increased, but age, gender, body mass index, rates of diabetes and smoking did not change over time. Open reduction internal fixation was the most commonly billed code, with 9,169 patients (53.6%), followed by hemiarthroplasty with 5,861 (34.2%) patients. Combined estimated probability of morbidity was 9.8% (standard deviation±5.2%), and did not change significantly over time. Postoperative complication rates were similar between treatments. CONCLUSION: Demographics and morbidity rates in femoral neck fractures of elderly patients did not change significantly from 2006 to 2015. Open reduction internal fixation was the most common treatment followed by hemiarthroplasty.

Trends in surgical treatment of femoral neck fractures in the elderly / Tendências no tratamento cirúrgico das fraturas do colo do fêmur em idosos

ABSTRACT Objective To analyze recent demographic and medical billing trends in treatment of femoral neck fracture of American elderly patients. Methods The American College of Surgeons National Surgical Quality Improvement Program database was analyzed from 2006 to 2015, for patients aged 65 years and older, using the Current Procedural Terminology codes 27130, 27125, 27235, and 27236. Patient demographics, postoperative complications, and frequency of codes were compared and analyzed over time. Our sample had 17,122 elderly patients, in that, 70% were female, mean age of 80.1 years (standard deviation±6.6 years). Results The number of cases increased, but age, gender, body mass index, rates of diabetes and smoking did not change over time. Open reduction internal fixation was the most commonly billed code, with 9,169 patients (53.6%), followed by hemiarthroplasty with 5,861 (34.2%) patients. Combined estimated probability of morbidity was 9.8% (standard deviation±5.2%), and did not change significantly over time. Postoperative complication rates were similar between treatments. Conclusion Demographics and morbidity rates in femoral neck fractures of elderly patients did not change significantly from 2006 to 2015. Open reduction internal fixation was the most common treatment followed by hemiarthroplasty.

RESUMO Objetivo Analisar tendências recentes demográficas e de faturamento médico no tratamento de fraturas do colo do fêmur em idosos americanos. Métodos O banco de dados National Surgical Quality Improvement Program, do American College of Surgeons, foi analisado de 2006 a 2015, para pacientes com idade igual ou superior a 65 anos, usando os códigos de Current Procedural Terminology 27130, 27125, 27235 e 27236. Dados demográficos dos pacientes, complicações pós-operatórias e frequência de códigos foram comparados e analisados ao longo do tempo. A amostra teve 17.122 pacientes geriátricos, sendo 70% do sexo feminino, com média de idade de 80,1 anos (desvio padrão±6,6 anos). Resultados O número de casos aumentou no período, mas idade, gênero, índice de massa corporal e taxas de diabetes e tabagismo não mudaram ao longo do tempo. A fixação interna de redução aberta foi o código faturado mais comum, com 9.169 pacientes (53,6%), seguido por artroplastia parcial do quadril, com 5.861 (34,2%) pacientes. A probabilidade estimada combinada de morbidade foi de 9,8% (desvio padrão±5,2%) e não mudou significativamente ao longo do tempo. As taxas de complicações pós-operatórias foram semelhantes entre os tratamentos. Conclusão Os dados demográficos e as taxas de morbidade relacionadas às fraturas geriátricas do colo do fêmur não apresentaram mudança significativa entre 2006 e 2015. A redução aberta e a fixação interna foram as opções de tratamento mais comuns, seguidas da artroplastia parcial do quadril.

Nationwide Analysis of Femoral Neck Fractures in Elderly Patients: A Receding Tide.

BACKGROUND: Geriatric femoral neck fractures are associated with substantial morbidity and medical cost. We evaluated the incidence and management trends of femoral neck fractures in recent years in the U.S. METHODS: Patient data from 2003 through 2013 were obtained from the Nationwide Inpatient Sample database. Femoral neck fractures in patients ≥65 years old were identified and grouped using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes for internal fixation, hemiarthroplasty, or total hip arthroplasty (THA). The nationwide incidence of femoral neck fractures was calculated and presented as an age-adjusted population rate. Univariable methods were used for trend analysis and comparisons between groups. Logistic regression modeling was used to analyze complications. RESULTS: From 2003 to 2013, we identified 808,940 femoral neck fractures in patients ≥65 years old. The national age-adjusted incidence of femoral neck fractures decreased from 242 per 100,000 U.S. adults in 2003 to 146 in 2013. The proportion of fractures managed operatively with THA increased over time (5.9% in 2003 versus 7.4% in 2013; p < 0.001). Concurrently, the use of hemiarthroplasty declined (65.1% versus 63.6%; p < 0.001). In 2013, the median age of the patients treated with THA was significantly younger (77.3 years) compared with that in the hemiarthroplasty and internal fixation groups (83.2 and 82.0 years). The THA group had significantly higher median initial hospital costs ($17,097) compared with the hemiarthroplasty and internal fixation groups ($14,776 and $10,462). CONCLUSIONS: In the last decade, the total number and population rate of femoral neck fractures in the elderly declined significantly. There was a modest but significant increase in the utilization of THA. CLINICAL RELEVANCE: This report identifies the changing trends in clinical practice in the treatment of geriatric femoral neck fractures in the U.S. Treating physicians should be aware of these trends, which include a decreasing national incidence of geriatric femoral neck fractures as well as an increase in the use of THA.

Trends in Surgical Management and Costs for Operative Treatment of Proximal Humerus Fractures in the Elderly.

Proximal humerus fractures in the elderly are increasing in frequency as the population ages. The purpose of this study was to investigate surgical and cost trends in the Medicare population. The PearlDiver database was queried using diagnosis codes to identify Medicare recipients with proximal humerus fractures from 2005 to 2012. Surgical trends, demographics, and charge/reimbursement data were analyzed. There were 750,426 proximal humerus fractures in Medicare recipients during the 8-year period. Eighty-five percent of the fractures were treated nonoperatively; however, the percentage of operative vs nonoperative management increased significantly over time for all fractures, isolated fractures, and fracture dislocations. Open reduction and internal fixation (ORIF) was the most common surgical treatment and remained constant. Reverse total shoulder arthroplasty (RTSA) increased by 406% and hemiarthroplasty (HEMI) decreased by 47%. Compared with younger patients, older patients were more likely to undergo HEMI or RTSA than to undergo ORIF for isolated fractures and fracture dislocations. Charges and reimbursements from Medicare increased over time. The charge to reimbursement gap increased from 87% in 2005 to 104% in 2012. Charges were higher for RTSA than for ORIF or HEMI. Nonoperative management was the treatment of choice for 85% of proximal humerus fractures in the elderly; however, there was a trend toward higher rates of surgery. The RTSA rate increased and the HEMI rate decreased, while ORIF remained constant. There was an increasing charge to reimbursement ratio for all procedure types. [Orthopedics. 2017; 40(4):e641-e647.].

Total Hip Arthroplasty and Hemiarthroplasty: US National Trends in the Treatment of Femoral Neck Fractures.

There is controversy regarding whether total hip arthroplasty (THA) or hemiarthroplasty (HA) is the treatment preferred for displaced intracapsular femoral neck fractures (FNFs). Using the US National Hospital Discharge Survey, we found that, of 12,757 patients admitted for FNF between 2001 and 2010, 4.6% underwent THA and 52.5% underwent HA. More of both procedures were performed over time. Mean age was higher for HA patients. Hospitalization duration and blood transfusion rates were higher for THA. There were region-based differences in frequency of THA and significant hospital-size-based differences in frequency of HA, possibly because of differences in regional training and subspecialist availability. In addition, a larger proportion of THA patients was covered by private insurance.

Disorder-related risk factors for revision total hip arthroplasty after hip hemiarthroplasty in displaced femoral neck fracture patients: a nationwide population-based cohort study.

BACKGROUND: The choice of primary hip hemiarthroplasty or total hip arthroplasty for displaced femoral neck fracture is still controversial. Revision hip arthroplasty not only increases risk and cost but also could result in worse outcome. Determining the risk factors for revision can help inform medical decision-making and aid in risk stratification of publicly reported outcomes. Therefore, we conducted a nationwide population-based study to identify the disease-related risk factors and construct a risk score nomogram to predict revision surgery. METHODS: Records of all 68,030 femoral neck fracture patients receiving partial hemiarthroplasty (HA) in 2000-2010, with no total hip arthroplasty (THA) or revision HA history, were collected from the National Health Insurance Research Database. Cox proportional hazard regression was used to estimate the risk of revision hip replacement (RHA). The score of each risk factor was the quotient of the regression coefficient of the variable by the regression coefficient for a 10-year increase in age. The predictive accuracy was tested using the area under the receiver operating characteristic curve (AUROC). RESULTS: The revision risk for hemiarthroplasty increased in male, those with schizophrenia and end-stage renal disease patients had 1.58-, 1.88-, and 1.74-fold revision HA risk (95 % confidence interval (CI) = 1.40-1.78, 1.26-2.79, and 1.29-2.34, respectively). In a predictive model, the cumulative risk score ranged from 0 to 13 with a 5.08 to 91.82 % 10-year predicted RHA risk. The percentage of AUROC for 10-year RHA risk in nomogram was 61.9 (95 % CI = 60.0-63.4). CONCLUSIONS: Males, schizophrenia and end-stage renal disease patients have higher risk of revision surgery after hemiarthroplasty for femoral neck fracture.

Trends in Primary and Revision Hip Arthroplasty Among Orthopedic Surgeons Who Take the American Board of Orthopedics Part II Examination.

BACKGROUND: A certified list of all operative cases performed within a 6-month period is a required prerequisite for surgeons taking the American Board of Orthopaedic Surgery Part II oral examination. Using the American Board of Orthopaedic Surgery secure Internet database database containing these cases, this study (1) assessed changing trends for primary and revision total hip arthroplasty (THA) and (2) compared practices and early postoperative complications between 2 groups of examinees, those with and without adult reconstruction fellowship training. METHODS: Secure Internet database was searched for all 2003-2013 procedures with a Current Procedural Terminology code for THA, hip resurfacing, hemiarthroplasty, revision hip arthroplasty, conversion to THA, or removal of hip implant (Girdlestone, static, or dynamic spacer). RESULTS: Adult reconstruction fellowship-trained surgeons performed 60% of the more than 33,000 surgeries identified (average 28.1) and nonfellowship-trained surgeons performed 40% (average 5.2) (P < .001). Fellowship-trained surgeons performed significantly more revision surgeries for infection (71% vs 29%)(P < .001). High-volume surgeons had significantly fewer complications in both primary (11.1% vs 19.6%) and revision surgeries (29% vs 35.5%) (P < .001). Those who passed the Part II examination reported higher rates of complications (21.5% vs 19.9%). CONCLUSION: In early practice, primary and revision hip arthroplasties are often performed by surgeons without adult reconstruction fellowship training. Complications are less frequently reported by surgeons with larger volumes of joint replacement surgery who perform either primary or more complex cases. Primary hip arthroplasty is increasingly performed by surgeons early in practice who have completed an adult reconstructive fellowship after residency training. This trend is even more pronounced for more complex cases such as revision or management of infection.

Trends in surgical management of proximal humeral fractures in the Medicare population: a nationwide study of records from 2009 to 2012.

BACKGROUND: Surgical management of proximal humeral fractures has reportedly increased in recent years. Much of this growth relates to a growing elderly population, together with the introduction of modern implants, such as locking plates and, recently, introduction of reverse shoulder arthroplasty (RSA). This study evaluated trends in surgical management of proximal humeral fractures from 2009 to 2012 by analyzing the use of hemiarthroplasty (HA), RSA, and osteosynthesis (open reduction with internal fixation [ORIF]) within the Medicare patient population. METHODS: We retrospectively reviewed a comprehensive Medicare patient population database within the PearlDiver supercomputer (Warsaw, IN, USA) for proximal humeral fractures treated with HA, RSA, or ORIF. Total use, annual utilization rates, age, and gender were investigated. RESULTS: Within the study period, 32,150 proximal humeral fractures were treated operatively, with no significant change in annual volume (P = .119). The percentage of fractures treated surgically decreased significantly from 16.2% to 13.9% (P < .001). The utilization rate decreased significantly for HA from 52% to 39% (P < .001), increased significantly for RSA from 11% to 28% (P < .001), and did not change significantly for ORIF (P = .164). The utilization rate of RSA nearly tripled for patients older than 65 years (11% to 29%) and doubled for patients younger than 65 (6% to 12%). CONCLUSION: From 2009 to 2012, utilization rates of ORIF remained fairly constant. HA remains the most commonly used surgical treatment for proximal humeral fractures in the Medicare population, but its use has declined significantly. This decline has been offset by a corresponding increase in RSA.

Outcomes after fixation for undisplaced femoral neck fracture compared to hemiarthroplasty for displaced femoral neck fracture among the elderly.

BACKGROUND: This study compared the rates of mortality, medical complication, and reoperation after fixation surgery for displaced femoral neck fracture with those after hemiarthroplasty surgery for undisplaced femoral neck fracture using competing risk analysis in inpatients aged 60 years and above from a population database in Taiwan. METHODS: We identified 13,772 subjects who underwent fixation for undisplaced cervical fracture and 13,772 matched controls who underwent hemiarthroplasty for displaced cervical fracture from 1998 to 2007, and followed them up until the end of 2009. The outcomes of patients who received internal fixation for undisplaced fracture and those of patients who received hemiarthroplasty for displaced fracture were compared. RESULTS: The 3-month, 2-year, and 10-year mortality rates were 4.9%, 22.1%, and 67.1% for fixation, and 5.6%, 23.8%, and 71.0% for hemiarthroplasty, respectively. The 3-month, 2-year, and 10-year cumulative incidence rates of the first reoperation were 7.4%, 18.1%, and 27.7% for fixation and 6.3%, 12.0%, and 22.3% for hemiarthroplasty, respectively. The 3-month cumulative incidence rates of the first medical complication were 14.4% for fixation and 15.4% for hemiarthroplasty, respectively. Hemiarthroplasty had a 1.09 times (95% CI: 1.05-1.12) higher hazard ratio for overall death than fixation. However, fixation had a 1.36 times (95% CI: 1.29-1.43) higher subdistribution hazard ratio for first reoperation than hemiarthroplasty after adjusting for gender, age, and comorbidities. CONCLUSIONS: The short-term overall mortality and medical complication rate of fixation for undisplaced fracture were slightly lower than those of hemiarthroplasty for displaced fracture. However, the short-term cumulative incidence of first reoperation after fixation was significantly higher than that for hemiarthroplasty. Further prospective studies or clinical trials based on the competing risk model, and which include important risk factors, are necessary to quantify the adjusted effects more precisely.

Low femoral antetorsion as a risk factor for bony impingement after bipolar hemiarthroplasty.

INTRODUCTION: Reports of dislocation after bipolar hemiarthroplasty (BHA) abound in literature, and several studies have mentioned the factors that are associated with an increased risk of dislocation. However, there is no report detailing the pattern of impingement in BHA and how femoral antetorsion can affect the range of motion (ROM) after BHA. PURPOSE: The purpose of this study was to evaluate the pattern of impingement in BHA and whether femoral antetorsion affects the ROM after BHA using three-dimensional (3D) dynamic motion analysis. METHODS: Using the computed tomography (CT) data of 60 patients (60 hips), including 31 men and 29 women who underwent BHA for the treatment of idiopathic osteonecrosis (ION) of the femoral head, we calculated the antetorsion of the femoral neck, ROM of flexion (Flex), internal rotation (Int-R), and external rotation (Ext-R) using a CT-based 3D simulation software. We evaluated the pattern of impingement and the relationship between femoral antetorsion and ROM in BHA. As for the implant position in the 3D simulation software, the anteversion of the femoral implant was set to be the same as the natural antetorsion of the femoral neck and neck length was set to be the standard neck in all cases. RESULTS: This study revealed the mechanism of impingement in BHA: (1) bone to bone impingement and (2) implant to bone impingement. We found a significant decrease in the ROM of Flex and Int-R inversely proportional to the femoral antetorsion. In patients with lower femoral antetorsion, the ROM of Flex and Int-R decreased due to bony impingement (the anterior great trochanteric region of the femur impinges on the anteroinferior edge of the anteroinferior iliac spine). Whereas, high anteversion of the femoral implant may decrease the ROM of Ext-R; however, our results also showed that even the lowest ROM of Ext-R with 10° hip extension was over 40°. CONCLUSIONS: We demonstrated that lower femoral antetorsion substantially affects the ROM of Flex and Int-R due to bony impingement. For these patients, there should be consideration given to retaining femoral "anterior offset" in BHA.

Current trends of stem use in hemiarthroplasty for femoral neck fracture in South Korea.

BACKGROUND: Hemiarthroplasty is a common operation to treat femoral neck fracture in elderly patients. The choice of whether to use cemented stem or cementless stem in hemiarthroplasty has been controversial in clinical practice. However, recent trends regarding stem choice in South Korea are not known or documented. In this study, we assessed the trends of stem fixation in hemiarthroplasty for femoral neck fractures in South Korea. METHODS: Data of patients with femoral neck fractures, who were operated on between the years of 2007 and 2011 and were ≥ 50 years old at the time of operation, were obtained from the Health Insurance Review and Assessment Service. All new visits or admissions to clinics or hospitals for femoral neck fractures were identified using the International Classification of Disease Tenth Revision diagnostic code (S720). The trends in the utilization of cemented and cementless hemiarthroplasty were then analyzed. RESULTS: The proportion of cementless hemiarthroplasty increased from 42.7% of all surgical procedures in 2007 to 61.4% of all surgical procedures in 2011 (p < 0.001), while the use of cemented hemiarthroplasty demonstrated a corresponding decrease. CONCLUSIONS: There was a current trends towards using cementless stems in hemiarthroplasty for femoral neck fractures in South Korea.

Surgical procedures in femoral neck fractures in Finland: a nationwide study between 1998 and 2011.

PURPOSE: For femoral neck fractures, recent scientific evidence supports cemented hemiarthroplasty (HA) over uncemented HA and suggests that total hip arthroplasty (THA) should be performed more frequently. We report the current surgical trends in treating femoral neck fractures in Finland. METHODS: The study was conducted using the Finnish National Hospital Discharge Register and included all Finns at least 50 years of age who underwent surgery for femoral neck fractures from 1998 through 2011. Age- and sex-specific incidence rates and annual proportion of each treatment method were calculated. RESULTS: During 1998-2011, a total of 49,514 operations for femoral neck fracture were performed in Finland. The proportion of uncemented HA increased from 8.1% in 2005 to 22.2% in 2011. During the same time, the proportion of cemented HA decreased from 63.9 to 52.5%, internal fixation decreased from 23.2 to 16.1% and THA increased from 4.9 to 9.2%. CONCLUSIONS: Between 2005 and 2011, the proportion of uncemented HA for femoral neck fractures increased markedly in Finland, while cemented HA and internal fixation declined. During this time, the use of THA nearly doubled. The current evidence-based guidelines for treatment of femoral neck fractures were mainly followed, but the increase in uncemented HA procedures contradicts recent scientific evidence.

The incidence of proximal humeral fractures in New York State from 1990 through 2010 with an emphasis on operative management in patients aged 65 years or older.

BACKGROUND: Proximal humeral fractures are commonly encountered injuries. The development of locking plate technology and reverse shoulder arthroplasty may have changed the treatment patterns of these fractures. METHODS: We used the Statewide Planning and Research Cooperative System database in New York State to determine the incidence of proximal humeral fractures from 1990 through 2010 and the choice of treatment: closed reduction-internal fixation, open reduction-internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA). RESULTS: The population-adjusted incidence per 100,000 increased from 15.35 in 1990 to 19.4 in 2010 (P < .0001). In patients aged 65 years or older, the incidence increased from 78.9 in 1990 to 101.0 in 2010 (P < .0001). In 1990, 20.4% of proximal humeral fractures were treated operatively; in 2010, this increased to 28.6% (P < .0001). Closed reduction-internal fixation/ORIF accounted for 58.4% of operative cases in 1990, decreasing to 46.6% in 2001 and increasing to 59.4% in 2010. HA was used in 27.1% of operative cases in 1990, increasing to 41% in 2001 and decreasing to 29.4% in 2010. TSA was used in 6.4% of operative cases in 1990, decreasing to 1.5% in 2001 with an increase to 7.5% in 2010. DISCUSSION: The incidence of proximal humeral fractures in patients aged 65 or older increased by 28% between 1990 and 2010, and operative management increased by more than 40%. The use of ORIF increased between 2001 and 2010, corresponding with the use of locking plate technology. There was an associated decrease in HA. TSA increased between 2006 and 2010, corresponding to the use of reverse shoulder arthroplasty.