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.

Are Femoral Stems in Primary Total Knee Arthroplasty Cost Effective in High Fracture Risk Patients? A Risk Model and Cost Analysis.

Femoral stemmed total knee arthroplasty (FS TKA) may be used in patients deemed higher risk for periprosthetic fracture (PPF) to reduce PPF risk. However, the cost effectiveness of FS TKA has not been defined. Using a risk modeling analysis, we investigate the cost effectiveness of FS in primary TKA compared with the implant cost of revision to distal femoral replacement (DFR) following PPF. A model of risk categories was created representing patients at increasing fracture risk, ranging from 2.5 to 30%. The number needed to treat (NNT) was calculated for each risk category, which was multiplied by the increased cost of FS TKA and compared with the cost of DFR. The 50th percentile implant pricing data for primary TKA, FS TKA, and DFR were identified and used for the analysis. FS TKA resulted in an increased cost of $2,717.83, compared with the increased implant cost of DFR of $27,222.29. At 50% relative risk reduction with FS TKA, the NNT for risk categories of 2.5, 10, 20, and 30% were 80, 20, 10, and 6.67, respectively. At 20% risk, FS TKA times NNT equaled $27,178.30. A 10% absolute risk reduction in fracture risk obtained with FS TKA is needed to achieve cost neutrality with DFR. FS TKA is not cost effective for low fracture risk patients but may be cost effective for patients with fracture risk more than 20%. Further study is needed to better define the quantifiable risk reduction achieved in using FS TKA and identify high-risk PPF patients.

What Are the Mortality, Infection, and Nonunion Rates After Periprosthetic Femoral Fractures in the United States?

BACKGROUND: Periprosthetic femoral fractures are a serious complication that put a high burden on patients. However, comprehensive analyses of their incidence, mortality, and complication rates based on large-registry data are scarce. QUESTIONS/PURPOSES: In this large-database study, we asked: (1) What is the incidence of periprosthetic femoral fractures in patients 65 years and older in the United States? (2) What are the rates of mortality, infection, and nonunion, and what factors are associated with these outcomes? METHODS: In this retrospective, comparative, large-database study, periprosthetic femoral fractures occurring between January 1, 2010, and December 31, 2019, were identified from Medicare physician service records encompassing services rendered in medical offices, clinics, hospitals, emergency departments, skilled nursing facilities, and other healthcare institutions from approximately 2.5 million enrollees. These were grouped into proximal, distal, and shaft fractures after TKA and THA. We calculated the incidence of periprosthetic femur fractures by year. Incidence rate ratios (IRR) were calculated by dividing the incidence in 2019 by the incidence in 2010. The Kaplan-Meier method with Fine and Gray subdistribution adaptation was used to calculate the cumulative incidence rates of mortality, infection, and nonunion. Semiparametric Cox regression was applied with 23 measures as covariates to determine factors associated with these outcomes. RESULTS: From 2010 to 2019, the incidence of periprosthetic femoral fractures increased steeply (TKA for distal fractures: IRR 3.3 [95% CI 1 to 9]; p = 0.02; THA for proximal fractures: IRR 2.3 [95% CI 1 to 4]; p = 0.01). One-year mortality rates were 23% (95% CI 18% to 28%) for distal fractures treated with THA, 21% (95% CI 19% to 24%) for proximal fractures treated with THA, 22% (95% CI 19% to 26%) for shaft fractures treated with THA, 21% (95% CI 18% to 25%) for distal fractures treated with TKA , 22% (95% CI 17% to 28%) for proximal fractures treated with TKA, and 24% (95% CI 19% to 29%) for shaft fractures treated with TKA. The 5-year mortality rate was 63% (95% CI 54% to 70%) for distal fractures treated with THA, 57% (95% CI 54% to 62%) for proximal fractures treated with THA, 58% (95% CI 52% to 63%) for shaft fractures treated with THA, 57% (95% CI 52% to 62%) for distal fractures treated with TKA , 57% (95% CI 49% to 65%) for proximal fractures treated with TKA, and 57% (95% CI 49% to 64%) for shaft fractures treated with TKA. Age older than 75 years, male sex, chronic obstructive pulmonary disease (HR 1.48 [95% CI 1.32 to 1.67] after THA and HR 1.45 [95% CI 1.20 to 1.74] after TKA), cerebrovascular disease after THA, chronic kidney disease (HR 1.28 [95% CI 1.12 to 1.46] after THA and HR 1.50 [95% CI 1.24 to 1.82] after TKA), diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis were clinical risk factors for an increased risk of mortality. Within the first 2 years, fracture-related infections occurred in 5% (95% CI 4% to 7%) of patients who had distal fractures treated with THA, 5% [95% CI 5% to 6%]) of patients who had proximal fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had shaft fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had distal fractures treated with TKA , 7% (95% CI 5% to 9%) of patients who had proximal fractures treated with TKA, and 6% (95% CI 4% to 8%) of patients who had shaft fractures treated with TKA. Nonunion or malunion occurred in 3% (95% CI 2% to 4%) of patients with distal fractures treated with THA, 1% (95% CI 1% to 2%) of patients who had proximal fractures treated with THA, 2% (95% CI 1% to 3%) of patients who had shaft fractures treated with THA, 4% (95% CI 3% to 5%) of those who had distal fractures treated with TKA, , 2% (95% CI 1% to 4%) of those who had proximal fractures treated with TKA, and 3% (95% CI 2% to 4%) of those who had shaft fractures treated with TKA. CONCLUSION: An increasing number of periprosthetic fractures were observed during the investigated period. At 1 and 5 years after periprosthetic femur fracture, there was a substantial death rate in patients with Medicare. Conditions including cerebrovascular illness, chronic kidney disease, diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis are among the risk factors for increased mortality. After the surgical care of periprosthetic femur fractures, the rates of fracture-related infection and nonunion were high, resulting in a serious risk to affected patients. Patient well-being can be enhanced by an interdisciplinary team in geriatric traumatology and should be improved to lower the risk of postoperative death. Additionally, it is important to ensure that surgical measures to prevent fracture-related infections are followed diligently. Furthermore, there is a need to continue improving implants and surgical techniques to avoid often-fatal complications such as fracture-associated infections and nonunion, which should be addressed in further studies. LEVEL OF EVIDENCE: Level III, therapeutic study.

The increasing complexity of femoral fragility fractures: incidence, fracture patterns and management over a 10-year period.

INTRODUCTION: The purpose of this study was to determine whether there have been changes in the numbers and complexity of femoral fragility fractures presenting to our department over a period of 10 years. METHODS: Patients >60 years presenting with femoral fragility fractures to our institution in 2018-2019 (397 fractures) were compared with respect to demographic data, incidence rates, fracture classification and surgical management with a historical cohort from 2009-2010 (335 fractures). Pathological and high velocity fractures were excluded. RESULTS: The gender proportion and average age (83.1 vs. 82.7 years) was unchanged. The number of femoral fractures increased by 19% but the overall incidence in people >60 years fell by 6% (p = 0.41). The proportion of unstable trochanteric fractures (31A2 and A3) increased from 22% to 55% (p < 0.001). The proportion of displaced intracapsular fractures increased from 53% to 72% (p < 0.001). The incidence of stable trochanteric fractures fell from 12.4 to 7.3/10,000 patients>60 years (p = 0.0006) while the incidence of unstable trochanteric fractures (31A2 and 31A3) increased from 3.5 to 8.9/10,000 patients >60 years (p < 0.0001). The proportion of trochanteric fractures treated with an intramedullary (IM) nail increased from 9% to 35% (p = 0.0001). The number of shaft and distal femoral fractures increased by 41% although the incidence did not change significantly. Periprosthetic fractures comprised 70% of femoral shaft fractures in both cohorts. CONCLUSIONS: The increasing number and complexity of femoral fragility fractures, especially unstable trochanteric fractures and periprosthetic fractures, is likely to have an impact on implant use, theatre time and cost.

Strikingly High Rates of Periprosthetic Joint Infection Following Revision Surgery for Periprosthetic Fractures Regardless of Surgery Timing.

BACKGROUND: Periprosthetic fractures following total hip arthroplasty (THA) often occur in the early postoperative period. Recent data has indicated that early revisions are associated with higher complication rates, particularly periprosthetic joint infection (PJI). The purpose of this study was to assess the effect of timing of periprosthetic fracture surgery on complication rates. We hypothesized that complication rates would be significantly higher in revision surgeries performed within 3 months of the index THA. METHODS: The Medicare Part A claims database was queried from 2010 to 2017 to identify patients who underwent surgery for a periprosthetic fracture following primary THA. Patients were divided based on time between index and revision surgeries: <1, 1 to 2, 2 to 3, 3 to 6, 6 to 9, 9 to 12, and >12 months. Complication rates were compared between groups using multivariate analyses to adjust for demographics, comorbidities, and types of revision surgery. RESULTS: Of 492,340 THAs identified, 4,368 (0.9%) had a subsequent periprosthetic fracture requiring surgery: 1,725 (39.4%) at <1 month, 693 (15.9%) at 1 to 2 months, 202 (4.6%) at 2 to 3 months, 250 (5.7%) at 3 to 6 months, 134 (3.1%) at 6 to 9 months, 85 (19.4%) at 9 to12 months, and 1,279 (29.3%) at >12 months. The risk of PJI was 11.0% in the <1 month group, 11.1% at 1 to 2 months, 7.9% at 2 to 3 months, 6.8% at 3 to 6 months, 8.2% at 6 to 9 months, 9.4% at 9 to 12 months, and 8.5% at >12 months (P = .12). Adjusting for confounding factors, risk of PJI following periprosthetic fracture surgery was similar regardless of timing (P > .05). Rates of subsequent dislocation and aseptic loosening were also similar regardless of timing. CONCLUSIONS: The risk of PJI following repeat surgery for a periprosthetic fracture was strikingly high regardless of timing (6.8 to 11.1%), underscoring the high-risk of complications.

Reducing the Burden of Disease Associated With Periprosthetic Fractures: Prevention and the Need for Improved Perioperative Care.

The management of periprosthetic fractures remains challenging and controversial. There continues to be a significant burden of disease and substantial resource implications associated with fractures following total joint arthroplasty. Achieving consensus opinions regarding the prevention and treatment of this problem has important implications given the profound effect on patient outcomes. Multidisciplinary care in the preoperative and postoperative settings is critical, with a specific focus on bone health.

Total Knee Arthroplasty in Patients with Spinal Cord Injury: Impact on Medical Complications, Hospital Costs and Length of Stay.

INTRODUCTION: Patients with spinal cord injury (SCI) with degenerative joint disease of the knee may require total knee arthroplasty (TKA). This study examines the demographic and immediate postoperative outcomes of patients with SCI who undergo TKA. METHODS: Admissions data for TKA and SCI were analyzed from the National Inpatient Sample database using International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes. An extensive array of preoperative and postoperative variables was compared among SCI TKA patients and non-SCI TKA patients. An unmatched and matched analysis using a 1:1 propensity match algorithm was conducted to compare the two groups. RESULTS: Patients with SCI tend to be younger and have a 7.518 times greater risk of acute renal failure, 2.3 times greater risk of blood loss, and higher risk of local complications, including periprosthetic fracture and prosthetic infection. The average length of stay in the SCI cohort was 2.12 times greater, with a 1.58 times higher mean total incurred charge than the non-SCI group. CONCLUSION: SCI is associated with an increased risk of acute renal failure, blood loss anemia, periprosthetic fractures and infections, a longer length of stay, and greater incurred charges in TKA patients. STUDY DESIGN: Retrospective study.

Incidence of Instability Following Primary Total Hip Arthroplasty Continues to Decline in the Medicare Population.

BACKGROUND: Instability has been the primary cause of failure following primary total hip arthroplasty (THA) leading to revision hip surgery. The purpose of this study was to determine if instability rates have further declined following advances in primary THA, including dual mobility articulations, direct anterior approaches, advanced technologies, and improved knowledge of the hip-spine relationships. METHODS: Using the 5% Medicare Part B claims data from 1999 to 2019, we identified 81,573 patients who underwent primary THA for osteoarthritis. Patients who experienced instability at 3 months, 6 months, 1 year, and 2 years were identified. Multivariate cox regression analyses evaluated the effect of patient and procedure characteristics on the risk of instability. RESULTS: Instability at 1 year following primary THA declined from approximately 4% in 2000 to 2.3% in 2010 and 1.6% in 2018. The leading cause of revision surgery was infection (18.6%), followed by periprosthetic fracture (14%), mechanical loosening (11.5%), and instability (9.4%). High-risk groups for instability continue to include increased age, higher Charlson index, obesity, lumbar spine pathology, and neurocognitive disorders. CONCLUSION: Instability is no longer the leading etiology of failure following primary THA with a decline of approximately 40% over the past decade. Infection, periprosthetic fracture, mechanical loosening, and then instability are now the leading causes of failure. Multiple factors may play a role in the decline of instability, including increased use of dual mobility articulations, direct anterior approaches, improved knowledge of the hip-spine relationships, and use of advanced technologies.

Cemented Femoral Fixation in Total Hip Arthroplasty Reduces the Risk of Periprosthetic Femur Fracture in Patients 65 Years and Older: An Analysis From the American Joint Replacement Registry.

BACKGROUND: Periprosthetic femur fracture (PPFx) is a devastating complication after total hip arthroplasty (THA). Despite concerns for increased PPFx, cementless fixation predominates in the United States. This study used the American Joint Replacement Registry to compare PPFx risk between cemented and cementless femoral fixation for THA. METHODS: An analysis of primary THA cases in patients aged 65 years and more was performed with the American Joint Replacement Registry data linked to Centers for Medicare and Medicaid Services data from 2012 to 2020. Analyses compared cemented to cementless femoral fixation. We identified 279,052 primary THAs, 266,040 (95.3%) with cementless and 13,012 (4.7%) with cemented femoral fixation. Cox proportional hazard regression analyses evaluated the association of fixation and PPFx risk, while adjusting for sex, age, and competing risk of mortality. Cumulative incidence function survival curves evaluated time to PPFx. RESULTS: Age ≥ 80 years (P < .0001) and women (P < .0001) were associated with PPFx. Compared to cemented stems, cementless stems had an elevated risk of PPFx (Hazards Ratio 7.70, 95% Confidence interval 3.2-18.6, P < .0001). The cumulative incidence function curves demonstrated an increased risk for PPFx across all time points for cementless stems, with equal magnitude of risk to 8 years.` CONCLUSION: Cementless femoral fixation in THA continues to predominate in the United States, with cementless femoral fixation demonstrating increased risk of PPFx in patients aged 65 years or more. Surgeons should consider greater use of cemented femoral fixation in this population to decrease the risk of PPFx.

Simultaneous bilateral total knee arthroplasty has higher in-hospital complications than both staged surgeries: a nationwide propensity score matched analysis of 38,764 cases.

PURPOSE: To investigate (1) healthcare utilization, (2) in-hospital metrics and (3) total in-hospital costs associated with simultaneous versus staged BTKA while evaluating staged BTKA as a single process consisting of two combined episodes. METHODS: The national readmissions database was reviewed for simultaneous and staged (two primary unilateral TKAs12 months apart) BTKA patients (2016-2017). A total of 19,382 simultaneous BTKAs were identified, and propensity score matched (1:1) to staged BTKA patients (19,382 patients; 38,764 surgeries) based on demographics, comorbidities, and socioeconomic determinants. Outcomes included healthcare utilization [length of stay (LOS) and discharge disposition], in-hospital periprosthetic fractures, non-mechanical complications, and costs. Staged BTKA was evaluated as one process consisting of two episodes. For each staged patient, continuous outcomes were evaluated via the sum of both episodes. Categorical outcomes were added, and percents were expressed relative to total number of surgeries (n = 38,764). RESULTS: Simultaneous BTKA had longer LOS (5.0 days ± 4.7 vs. 4.5 days ± 3.5; p < 0.001), higher non-home discharge [36.9% (n = 7150/19,382) vs. 13.6% (n = 5451/38,764)], in-hospital periprosthetic fractures [0.13% (26/19,382) vs. 0.08% (31/38,764); p = 0.049], any non-mechanical complication [33.76% (6543/19,382) vs.15.93% (6177/38,764); p < 0.0001], hematoma/seroma formation [0.11% (22/19,382) vs. 0.05% (20/38,764); p = 0.0088], wound disruption [0.08% (16/19,382) vs. 0.04% (16/38,764); p = 0.0454], and any infection [1.13% (219/19,382) vs. 0.50% (194/38,764); p < 0.0001]. Average in-hospital costs for the two staged BTKA episodes combined were $5006 higher than those of simultaneous BTKA ($28,196 ± $18,488 vs. $33,202 ± $15,240; p < 0.001). CONCLUSION: Simultaneous BTKA had higher healthcare utilization and in-hospital complications than both episodes of staged BTKA combined, with a minimal in-hospital cost savings. Future studies are warranted to further explore patient selection who would benefit from BTKA.

A cost analysis of treating postoperative periprosthetic femoral fractures following hip replacement surgery in a UK tertiary referral centre.

AIM: This study aims to evaluate costs associated with periprosthetic femoral fracture (PFF) treatment at a UK tertiary referral centre. METHODS: This study included 128 consecutive PFFs admitted from 02/04/2014-19/05/2020. Financial data were provided by Patient Level Information and Costing Systems. Primary outcomes were median cost and margin. Secondary outcomes were length of stay, blood transfusion, critical care, 30-day readmission, 2-year local complication, 2-year systemic complication, 2-year reoperation and 30-day mortality rates. Statistical comparisons were made between treatment type. Statistical significance was set at p<0.05. RESULTS: Across the cohort, median cost was £15,644.00 (IQR £11,031.00-£22,255.00) and median loss was £3757.50 (£599.20-£8296.20). The highest costs were ward stay (£3994.00, IQR £1,765.00-£7,013.00), theatre utilisation (£2962.00, IQR £0.00-£4,286.00) and overheads (£1705.10, IQR £896.70-£2432.20). Cost (£17,455.00 [IQR, £13,194.00-£23,308.00] versus £7697.00 [IQR £3871.00-£10,847.00], p<0.001) and loss (£4890.00 [IQR £1308.00-£10,009.00] versus £1882.00 [IQR £313.00-£3851.00], p = 0.02) were greater in the operative versus the nonoperative group. There was no difference in cost (£17,634.00 [IQR £12,965.00-£22,958.00] versus £17,399.00 [IQR £13,394.00-£23,404.00], p = 0.98) or loss (£5374.00 [IQR £1950.00-£10,143.00] versus £3860.00 [IQR -£95.50-£7601.00], p = 0.21) between the open reduction and internal fixation (ORIF) and revision groups. More patients required blood transfusion in the operative versus the nonoperative group (17 [17.9%] versus 0 [0.0%], p = 0.009). There was no difference in any clinical outcome between the ORIF and revision groups (p>0.05). CONCLUSION: PFF treatment costs are high with inadequate reimbursement from NHS tariff. Work is needed to address this disparity and reduce hospital costs. Cost should not be used to decide between ORIF and revision surgery.

Epidemiology and characteristics of femoral periprosthetic fractures : data from the characteristics, outcomes and management of periprosthetic fracture service evaluation (COMPOSE) cohort study.

AIMS: The aim of this study was to describe the demographic details of patients who sustain a femoral periprosthetic fracture (PPF), the epidemiology of PPFs, PPF characteristics, and the predictors of PPF types in the UK population. METHODS: This is a multicentre retrospective cohort study including adult patients presenting to hospital with a new PPF between 1 January 2018 and 31 December 2018. Data collected included: patient characteristics, comorbidities, anticoagulant use, social circumstances, level of mobility, fracture characteristics, Unified Classification System (UCS) type, and details of the original implant. Descriptive analysis by fracture location was performed, and predictors of PPF type were assessed using mixed-effects logistic regression models. RESULTS: In total, 720 femoral PPFs from 27 NHS sites were included. PPF patients were typically elderly (mean 79.9 years (SD 10.6)), female (n = 455; 63.2%), had at least one comorbidity (n = 670; 93.1%), and were reliant on walking aids or bed-/chair-bound prior to admission (n = 419; 61.7%). The study population included 539 (74.9%) hip PPFs, 151 (21.0%) knee PPFs, and 30 (4.2%) dividing type PPFs. For hip (n = 407; 75.5%) and knee (n = 88; 58.3%) arthroplasty UCS B type fractures were most common. Overall, 556 (86.2%) were treated in the presenting hospital and 89 (13.8%) required transfer for treatment. Female sex was the only significant predictor of fracture type (A/B1/C type versus B2/B3) for femoral hip PPFs (odds ratio 0.61 (95% confidence interval 0.41 to 0.91); p = 0.014). Sex, residence type, primary versus revision implant PPF, implant fixation, and time between arthroplasty and PPF were not found to predict fracture type for hip PPFs. CONCLUSION: This multicentre analysis describes patient and injury factors for patients presenting with femoral PPFs to centres across the UK. These patients are generally elderly and frail, comparable to those sustaining a hip fracture. These data can be useful in planning future services and clinical trials. Cite this article: Bone Joint J 2022;104-B(8):987-996 .

Complications During the Hospital Stay, Length of Stay, and Cost of Care in Parkinson Patients Undergoing Total Knee Arthroplasty: A Propensity Matched Database Study.

BACKGROUND: Patients with Parkinson disease (PD) undergoing total knee arthroplasty (TKA) can present with a unique subset of challenges during their hospital stay. The literature is limited to single-center studies with a small number of patients. This study was aimed to analyze the inpatient complications, length of stay (LOS), and cost of care (COC) associated after TKA with PD over 4 years (2016 to 2019). METHODS: In this retrospective cohort study, we used National Inpatient Sample (NIS) database data from 2016 to 2019 and compared in-hospital complications, LOS, and COC among patients undergoing TKA with and without PD. RESULTS: The National Inpatient Sample database is used to identify 558,371 patients (555,289 without PD and 3,082 with PD) who underwent TKA. After propensity-matching, there was an increased incidence of blood loss anemia (PD group 22.3%, control group 13.5%, P ≤ 0.01), periprosthetic dislocations (1.5% in PD group, 0.4% in control group, P < 0.001), and periprosthetic mechanical complications including but not limited to periprosthetic fractures, knee dislocations, patellar maltracking, and subluxations (1.1% in PD group, 0.6% in control group, P = 0.024) in the PD group. The other in-hospital complications including mortality, acute renal failure, myocardial infarction, pneumonia, pulmonary embolism, deep vein thrombosis, periprosthetic fracture, and wound dehiscence showed no notable differences. The average total incurred charges for the PD group were higher, with a mean of $67,581.58 (SD $44,554.64), than that in the control group, with a mean of $64,795.51 (SD $45,841.25) (P < 0.001). The average LOS was higher in the PD group with a mean of 2.7 days (SD = 1.93) compared with the control group (mean = 2.3, SD = 1.73 days, P < 0.001). CONCLUSIONS: An increased incidence of complications such as acute blood loss anemia, periprosthetic mechanical complications, and increased COC, but no difference in LOS was noted in patients undergoing TKA with PD. This information can be useful to make an informed decision regarding patient care and preferred healthcare setup for TKA in patients with PD.

Fracture Risk Assessment Tool Scores and Radiographical Bone Measurements in Total Hip Arthroplasty Patients.

BACKGROUND: Osteoporosis is a major risk factor for periprosthetic fractures (PPFx) in total hip arthroplasty (THA) patients but is not routinely screened for in this population. Given the availability of hip x-rays and preoperative screenings, Fracture Risk Assessment Tool (FRAX) scores and radiographic bone measurements are potentially promising, novel risk stratification tools. This study aims to characterize FRAX scores and radiographic bone measurements in THA and PPFx patients. METHODS: A retrospective chart review for demographic variables and FRAX scores was performed on 250 THA and 40 PPFx patients. Radiographic bone measurements including cortical thicknesses (both antero-posterior [AP] and lateral), canal to calcar ratio, canal flare index, and Dorr classifications were obtained from preoperative x-rays. Correlation between FRAX scores and radiographic bone measurements was investigated with linear regressions. FRAX scores and radiographic bone measurements were compared between the THA and PPFx patients. Multivariate logistic regressions were used to identify factors predicting PPFx. RESULTS: FRAX scores were significantly correlated with both AP (P < .001) and lateral (P = .007) cortical thicknesses. Compared to THA patients, those with PPFx had significantly higher FRAX scores (P = .003) and lower AP cortical thickness (P = .005). Multivariate logistic regressions demonstrated that FRAX major osteoporotic fracture risk score and AP cortical thickness were independent predictors of PPFx (P = .001 and .024, respectively). CONCLUSION: Cortical thicknesses are good proxy measurements of osteoporosis-related fracture risk in THA patients. In addition, both major and AP cortical thickness indices are promising tools for identifying patients who are at a high risk of PPFx in the THA population.

Reverse total shoulder arthroplasty in patients 80 years and older: a national database analysis of complications and mortality.

BACKGROUND: Although reverse total shoulder arthroplasty (RSA) is considered a safe surgical option in elderly patients, large-scale analyses of complications and mortality after RSA in patients 80 years and older are scarce. The goals of the current study were to identify revision, complication, and early mortality rates after RSA in patients 80 years and older and compare these to younger patients. METHODS: The PearlDiver Database, which contains services rendered to Medicare, Medicaid, and commercial insurance patients, was queried for patients undergoing RSA using International Classification of Diseases, Ninth/Tenth Revision (ICD-9/ICD-10) procedure codes. Patients were separated into 2 groups based on their age: 80 years and older and <80 years of age. The incidence of revision arthroplasty, medical, and surgical complications after RSA were extracted. Multivariate regression was used to compare revision arthroplasty and complication rates between groups. Statistical significance was set at P <.05. RESULTS: A total of 29,430 cases of RSA were included, with 486 cases in patients 80 years and older (median age, 80 years; age range, 2 years). Patients 80 years and older had 1- and 2-year revision rates of 3.9% and 5.1%, compared with the younger cohort at 3.0% and 3.1%, respectively. In patients 80 years and older, there were higher rates of deep venous thrombosis (DVT) (odds ratio [OR] 2.87, 95% CI 1.5-4.97), urinary tract infection (OR 1.42, 95% CI 1.01-1.94), acute renal failure (OR 2.18, 95% CI 1.44-3.17), and pneumonia (OR 1.75, 95% CI 1.09-2.68) within 90 days postoperatively. Ninety-day surgical complications were similar between the cohorts; however, younger patients experienced higher rates of dislocation, stiffness, periprosthetic fracture, and implant complications 1 year postoperatively. Patients 80 years and older had a significantly higher 90-day mortality rate at 2.7% compared with 1.5% in younger patients (P = .002). CONCLUSIONS: RSA is a generally safe procedure even in patients 80 years and older, with low complication and revision rates. Patients 80 years and older had higher early mortality and medical complication rates, including DVT, renal failure, and pneumonia than patients <80 years of age. However, patients 80 years and older had lower rates of dislocation, periprosthetic fracture, and implant-related complication at 1 year postoperatively.

The Economic Impact of Lower Extremity Periprosthetic Fractures in a Large Hospital System.

BACKGROUND: Periprosthetic fractures (PPFs) place a burden on hospital systems. They occur in older patients with medical comorbidities, as unplanned events requiring technically complex surgeries with expensive implants. The purpose of this study was to describe this patient population and evaluate the economic impact of PPFs on a hospital system. METHODS: We conducted a retrospective study of PPFs of the hip and knee between 2018 and 2019. Demographics, length of stay (LOS), and discharge disposition were collected. We performed chart and radiographic reviews to determine the fracture classification and type of treatment performed. An analysis of direct inpatient costs was performed and categorized by a fracture type. RESULTS: We identified 213 periprosthetic hip and 151 periprosthetic knee fractures. The mean age of hip patients was 77 years, and 71% were female. The average surgery time was 194 minutes, LOS was 5.01 days, and 71% were discharged to a skilled nursing facility (SNF). The mean age of knee patients was 76 years, and 79% were female. The average surgery time was 174 minutes, LOS was 5.12 days, and 70% were discharged to a SNF. The median direct cost of hip fractures was $17,108, with Vancouver B2 and B3 costing significantly more at $19,987 and $23,935, respectively (P value <.0001). The median direct cost of knee fractures was $13,713. Type 3 distal femur fractures cost significantly more at $37,445 (P value <.0001). CONCLUSION: PPFs create a significant economic impact on hospital systems. We stratified the costs of treatment based on the fracture type. Significantly higher costs are associated with injuries requiring revision implants.

The Impact of Femoral Component Cementation on Fracture and Mortality Risk in Elective Total Hip Arthroplasty: Analysis from a National Medicare Sample.

BACKGROUND: Complications following elective total hip arthroplasty (THA) are rare but potentially devastating. The impact of femoral component cementation on the risk of periprosthetic femoral fractures and early perioperative death has not been studied in a nationally representative population in the United States. METHODS: Elective primary THAs performed with or without cement among elderly patients were identified from Medicare claims from 2017 to 2018. We performed separate nested case-control analyses matched 1:2 on age, sex, race/ethnicity, comorbidities, payment model, census division of facility, and exposure time and compared fixation mode between (1) groups with and without 90-day periprosthetic femoral fracture and (2) groups with and without 30-day mortality. RESULTS: A total of 118,675 THAs were included. The 90-day periprosthetic femoral fracture rate was 2.0%, and the 30-day mortality rate was 0.18%. Cases were successfully matched. The risk of periprosthetic femoral fracture was significantly lower among female patients with cement fixation compared with matched controls with cementless fixation (OR = 0.83; 95% CI, 0.69 to 1.00; p = 0.05); this finding was not evident among male patients (p = 0.94). In contrast, the 30-day mortality risk was higher among male patients with cement fixation compared with matched controls with cementless fixation (OR = 2.09; 95% CI, 1.12 to 3.87; p = 0.02). The association between cement usage and mortality among female patients almost reached significance (OR = 1.74; 95% CI, 0.98 to 3.11; p = 0.06). CONCLUSIONS: In elderly patients managed with THA, cemented stems were associated with lower rates of periprosthetic femoral fracture among female patients but not male patients. The association between cemented stems and higher rates of 30-day mortality was significant for male patients and almost reached significance for female patients, although the absolute rates of mortality were very low. For surgeons who can competently perform THA with cement, our data support the use of a cemented stem to avoid periprosthetic femoral fracture in elderly female patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Current Incidence and Future Projection of Periprosthetic Fractures in South Korea: A Study Based on National Claim Database.

OBJECTIVE: To evaluate the current incidence and economic cost and to estimate the future burden of periprosthetic fracture (PF) after joint arthroplasties in South Korea. METHODS: This study was a retrospective registry-based study of patients who were diagnosed as periprosthetic fractures (PFs) in South Korea. Cases of PF from 2010 to 2017 in South Korea using Health Insurance and Review and Assessment (HIRA) database, which contains all medical claims for all South Korean patients, were identified. The operational definitions of PFs were identified from the Electronic Data Interchange (EDI) code of the Korean National Health Insurance Program (KHNIP). The annual incidence and medical costs during the period were calculated and the future increase of PF and its cost were projected through 2030 using generalized linear model with quasi-poisson link. RESULTS: During the 8-year period, 14,456 patients were treated due to PFs. The annual number of patients with PF remarkably increased from 1,322 in 2010 to 2,636 in 2017. The increment was prominent in age groups of 70-79 and ≧80. Total number of patients with PF were 9752 in women and 4704 in men during the study period. Mean personal costs were 1,155.4 USD in women and 1,185.5 USD in men. The total cost of PFs increased from 779,533 USD in 2010 to 3,888,402 USD in 2017. The personal cost of PFs also increased from 589.7 USD in 2010 to 1,475.1 USD in 2017. In 2017, the number of PF patients exponentially increased after 50 years of age especially in women. Estimated with our projection model, the number of PFs will increase by 2.5 times and the cost will increase by 10 times in the next 10 years. CONCLUSION: The incidence and cost of PFs are rising and will represent a serious socioeconomic burden in South Korea.

Assessment of morbidity and mortality after periprosthetic hip fracture. Influence of Vancouver stage in a retrospective single-centre study of 88 patients.

BACKGROUND: Peri-prosthetic hip fractures (PPHFs) are serious complications whose treatment is generally difficult due to their predominance in elderly patients with bone frailty and other comorbidities. The Vancouver classification is the most widely used and is helpful for assisting treatment decisions. However, its value for predicting morbidity and mortality has not been assessed. The objective of this retrospective study was to assess post-operative morbidity and mortality according to the fracture type in the Vancouver classification. HYPOTHESIS: Post-operative morbidity and mortality vary across fracture types in the Vancouver classification. METHODS: A single-centre retrospective study was conducted from 1st January 2010 to 31st December 2015. All patients who had surgery for a PPHF were included. There were 88 patients, including 66 (75%) females, and mean age was 82 years. The patients were re-evaluated at least 3 years after surgery. The distribution of the fracture types was as follows: Vancouver (V) A, n=7; VB, n=63 (VB1, n=30; VB2, n=23; and VB3, n=10); and VC, n=18. Data on the pre-operative status (self-sufficiency, comorbidities, ASA score, etc.) were extracted from the admission files. Morbidity and mortality were evaluated globally and according to the Vancouver type, using the patient files and telephone calls to determine self-sufficiency scores (Parker, Katz, and Lawton) and functional scores (Merle d'Aubigné-Postel [MAP] score and Harris Hip Score [HHS]). RESULTS: Post-operative medical complications were very common (33 [37.5%] patients) and correlated with the severity of the fracture. Similarly, the mortality rate at last follow-up varied significantly (p<0.05) with the severity of the fracture, as follows: VA, 28.5%; VB1, 40%; VB2, 47.8%; VC, 55.6%; and VB3, 66.7%). In the overall population, loss of self-sufficiency was 20%, 14%, and 26% according to Parker, Katz, and Lawton, respectively; loss of function was 13.9% and 13.3% according to the MAP score and HHS (p<0.05). All the self-sufficiency scores (Parker, Katz, and Lawton) and functional scores (MAP and HHS) decreased post-operatively in proportion to the severity of the fracture (very small losses for VA and greatest losses for VB3) (p<0.05). CONCLUSION: The short- and medium-term mortality rates in our cohort of patients with PPHFs were high and chiefly dependent on the severity of the fractures. The self-sufficiency and functional scores were better in the group with VA fractures than in the groups with VB1, VB2, VB3, and VC fractures. In any case, early weight-bearing is without doubt a key factor in limiting the impact of PPHFs on the functional outcome and on mortality. LEVEL OF EVIDENCE: IV, retrospective study.

An Assessment of Factors That Influence Outcome Following Fixation of Periprosthetic Distal Femur Fractures Associated with Total Knee Arthroplasty.

BACKGROUND: Periprosthetic distal femur fractures following total knee arthroplasty (PDFFTKA) are increasingly common [1], mainly in elderly patients with significant co-morbidities [2]. Surgical management usually requires balancing prompt fixation for early mobilization with the need to consider the least physiologically demanding option [3].The aim of this study was to assess predictors of clinical and radiological outcome in patients with PDFFTKA treated with open reduction and internal fixation (ORIF). MATERIALS AND METHODS: A retrospective cohort study of patients managed for PDFFTKA over the last 21 years in the Trauma & Orthopaedics Department of the Royal Shrewsbury Hospital (RSH) was carried out. Radiological images, pre- and post-operatively, were assessed for fracture related parameters. Last known functional status was evaluated using the most recent outpatient review letters. After assessment of normality of data, evaluation of predictors of clinical and radiological outcome was made using correlation analyses. RESULTS: There was no statistically significant correlation between age, primary TKA to fracture interval, and length of intact medial cortex vs clinical outcome for the parametric variables evaluated. For non-parametric variables assessed, there was a statistically significant correlation between clinical outcome and evidence of callus formation (Spearman rho value -0.476; p=0.022). In stratifying the patients with poor and good outcome, there was no difference noted in primary TKA to fracture interval, or length of intact medial cortex (mm) between both groups. In terms of the number of comminuted fragments and anterior flange to fracture distance (mm), there was also no difference noted between the poor and good functional groups. CONCLUSIONS: 1. There was no observed correlation in pre-operative patient and fracture related variables with outcome in this population of patients with PDFFTKA. 2. Post-operative evidence of callus formation appears to be directly related to better clinical outcomes.