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.

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.

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.

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 .

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.

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.

Medical resource utilization and costs for intraoperative and early postoperative periprosthetic hip fractures following total hip arthroplasty in the medicare population: A retrospective cohort study.

This study assessed the impact of intraoperative and early postoperative periprosthetic hip fractures (PPHFx) after primary total hip arthroplasty (THA) on health care resource utilization and costs in the Medicare population.This retrospective observational cohort study used health care claims from the United States Centers for Medicare and Medicaid Standard Analytic File (100%) sample. Patients aged 65+ with primary THA between 2010 and 2016 were identified and divided into 3 groups - patients with intraoperative PPHFx, patients with postoperative PPHFx within 90 days of THA, and patients without PPHFx. A multi-level matching technique, using direct and propensity score matching was used. The proportion of patients admitted at least once to skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and readmission during the 0 to 90 or 0 to 365 day period after THA as well as the total all-cause payments during those periods were compared between patients in PPHFx groups and patients without PPHFx.After dual matching, a total 4460 patients for intraoperative and 2658 patients for postoperative PPHFx analyses were included. Utilization of any 90-day post-acute services was statistically significantly higher among patients in both PPHFx groups versus those without PPHFx: for intraoperative analysis, SNF (41.7% vs 30.8%), IRF (17.7% vs 10.1%), and readmissions (17.6% vs 11.5%); for postoperative analysis, SNF (64.5% vs 28.7%), IRF (22.6% vs 7.2%), and readmissions (92.8% vs 8.8%) (all P < .0001). The mean 90-day total all-cause payments were significantly higher in both intraoperative ($30,114 vs $21,229) and postoperative ($53,669 vs $ 19,817, P < .0001) PPHFx groups versus those without PPHFx. All trends were similar in the 365-day follow up.Patients with intraoperative and early postoperative PPHFx had statistically significantly higher resource utilization and payments than patients without PPHFx after primary THA. The differences observed during the 90-day follow up were continued over the 1-year period as well.

Dual Diagnosis and Total Hip Arthroplasty.

The co-occurrence of a mental illness and a substance abuse disorder (SUD) is common and has been referred to as a "dual diagnosis" (DD). Although studies have independently investigated mental illness alone and SUD alone, few have examined the effects of these entities combined on complications. A search of the Medicare database from 2005 to 2012 identified 2000 DD patients who underwent total hip arthroplasty (THA). They were compared with 86,976 patients with mental illness only and 590,689 controls (no mental illness or SUD). Medical comorbidities and postoperative complications at 30-day, 90-day, and minimum 2-year time points were analyzed. There was a significant increase (P<.001) in 7 (53.8%) of 13 recorded postoperative medical complications, including acute renal failure (odds ratio [OR], 1.78), postoperative anemia (OR, 1.31), and blood transfusion (OR, 1.24), at the 90-day time point. In addition, there was a statistically significant increase overall in periprosthetic infection (periprosthetic joint infection OR, 4.30; P<.001), periprosthetic fracture (OR, 2.80; P<.001), dislocation (OR, 6.38; P<.001), and the need for THA revision (OR, 3.58; P<.001). When compared with patients with mental illness only, DD patients remained at significantly (P<.001) increased risk for 90-day and overall postoperative surgical complications, including dislocation, periprosthetic joint infection, and THA revision. Patients with a DD were at significant risk for perioperative complications compared with both control patients and patients with mental illness only. Studies investigating only psychiatric disease or only SUD may miss a vulnerable cohort. Further investigation is needed to exactly define to what extent DD amplifies complication rates. [Orthopedics. 2018; 41(3):e321-e327.].

Costs and Risk Factors for Hospital Readmission After Periprosthetic Knee Fractures in the United States.

BACKGROUND: Periprosthetic fractures (PPFX) around total knee arthroplasty (TKA) are devastating complications with significant morbidity. With growing healthcare costs, hospital readmissions have become a marker for quality healthcare delivery. However, little is known about the risk factors or costs associated with readmission after treatment of PPFX. We sought to identify the patient demographics, prevalence of treatment types (open reduction internal fixation [ORIF] vs revision TKA), 30 and 90-day readmission rates, costs of initial treatment and readmission, and risk factors for readmission. METHODS: We used the 2013 Nationwide Readmissions Database to select patients who underwent TKA, revision TKA, and treatment of PPFX with either ORIF or revision TKA. The 90-day readmission rate was determined through a survival analysis, and risk factors were identified using a cox proportional hazards model that adjusted for patient and hospital characteristics. RESULTS: We identified 1526 patients with PPFX treated with ORIF and 1458 treated with revision TKA. Ninety-day readmissions were 20.5% and 21.8%, respectively. Patients with ORIF were more often female and had multiple medical comorbidities. Patient factors associated with readmission included advanced age, male gender, comorbidities, discharge to a skilled nursing facility or home with health aide, and Medicare or Medicaid insurance. Treatment at a teaching hospital was the only hospital-associated risk factor identified. ORIF cost USD 25,539 and revision THA cost USD 37,680, with associated readmissions costing 15,269 and 16,806, respectively. CONCLUSION: PPFX results in greater costs compared to primary and revision TKA. This study highlights risk factors for readmission after PPFX treatment.

Periprosthetic knee fractures. A review of epidemiology, risk factors, diagnosis, management and outcome.

BACKGROUND AND AIM OF THE WORK: Periprosthetic knee fractures incidence is gradually raising due to aging of population and increasing of total knee arthroplasties. Management of this complication represents a challenge for the orthopaedic surgeon. Aim of the present study is to critically review the recent literature about epidemiology, risk factors, diagnosis, management and outcome of periprosthetic knee fractures. METHODS: A systematic search of Embase, Medline and Pubmed was performed by two reviewers who selected the eligible papers favoring studies published in the last ten years. Epidemiology, risk factors, diagnostic features, clinical management and outcome of different techniques were all reviewed. RESULTS: 52 studies including reviews, meta-analysis, clinical and biomechanical studies were selected. CONCLUSIONS: Correct clinical management requires adequate diagnosis and evaluation of risk factors. Conservative treatment is rarely indicated. Locking plate fixation, intramedullary nailing and revision arthroplasty are all valuable treatment methods. Surgical technique should be chosen considering age and functional demand, comorbidities, fracture morphology and location, bone quality and stability of the implant. Given the correct indication all surgical treatment can lead to satisfactory clinical and radiographic results despite a relevant complication rate.

Frequency and Treatment Trends for Periprosthetic Fractures About Total Hip Arthroplasty in the United States.

BACKGROUND: Periprosthetic hip fractures (PPHFx) are challenging complications that have become increasingly more prevalent. Wide variability exists in the quality and size of prior studies pertaining to hospital stay information. This study used the largest publicly available database in the United States to evaluate perioperative hospital data of PPHFx. METHODS: The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample was used to analyze trends related to the frequency, fracture type, mortality, treatment, patient demographics, time to surgery, length of stay (LOS), and hospital charges associated with PPHFx from 2006-2010. RESULTS: From 2006-2010, average patient age (76.7 years), hospital characteristics, rate of PPHFx, treatment choice, LOS (8.03 days), mortality (2.6%), disposition (78.1% to skilled nursing facility or inpatient rehab), and time to procedure (1.98 days) all remained relatively stable. The southern United States had the highest frequency of PPHFx and females had nearly twice the rate of PPHFx each year at an average of 67%. Despite these consistencies, hospital charges increased by an average of 8.3% per year over the study period ($27,683 over 5 years, P < .0001). CONCLUSION: In the era of containing cost while improving quality of care, this study demonstrates that despite consistent treatment trends of PPHFx, hospital charges are increasing independently. Regardless, surgeons can work to reduce LOS and charge to post acute care facilities to lessen spending. Refining our understanding of these relationships will be fundamental to further improving quality of care and cutting cost associated with these fractures.

Should We Think Twice About Psychiatric Disease in Total Hip Arthroplasty?

BACKGROUND: Psychiatric disease (PD) is common, and the effect on complications in total hip arthroplasty (THA) is poorly understood. The purpose of this study was to evaluate the medical and surgical postoperative complication profile in patients with PD, and we hypothesize that they will be significantly increased compared with control group. METHODS: A search of the entire Medicare database from 2005 to 2011 was performed using International Classification of Disease version 9 codes to identify 86,976 patients who underwent primary THA with PD including bipolar (5626), depression (82,557), and schizophrenia (3776). A cohort of 590,689 served as a control with minimum 2-year follow-up. Medical and surgical complications at 30-day, 90-day, and overall time points were compared between the 2 cohorts. RESULTS: Patients with PD were more likely to be younger (age < 65 years; odds ratio [OR] = 4.51, P < .001), female (OR = 2.02, P < .001) and more medically complex (significant increase in 28/28 Elixhauser medical comorbidities, P < .001). There was a significant increase (P < .001) in 13/14 (92.8%) recorded postoperative medical complications rates at the 90-day time point. In addition, there was a statistically significant increase in periprosthetic infection (OR = 2.26, P < .001), periprosthetic fracture (OR = 2.09, P < .001), dislocation (OR = 2.30, P < .001), and THA revision (OR = 1.93, P < .001) at overall follow-up. CONCLUSION: Patients with PD who undergo elective primary THA have significantly increased medical and surgical complication rates in the global period and short-term follow-up, and these patients need to be counseled accordingly.

Periprosthetic humeral fractures associated with reverse total shoulder arthroplasty: incidence and management.

PURPOSE: The purpose of this study was to record the incidence and management of periprosthetic humeral fractures (PHF) using reverse total shoulder arthroplasty (RTSA) in our institution. METHODS: We performed a retrospective study of 203 RTSA implanted in 200 patients between 2003 and 2014. The mean follow-up was 78.82 months (range, 12-141). Mean age of the study cohort was 75.87 years (range, 44-88). There were only 25 male patients (12.5 %). We assessed the presence of periprosthetic humeral fractures studying the medical files and X-rays of all patients. RESULTS: We identified seven periprosthetic humeral fractures in 203 RTSA (3.4 %): three intra-operative (1.47 %) and four post-operative (1.97 %). The average age at the time of the fracture was 75.14 years (59-83). All patients were women (100 %). Three patients with post-operative fractures type B were treated by osteosynthesis, and one patient with post-operative fracture type A was treated conservatively. All intra-operative fractures needed cerclage wire and in one case long cemented stem. All our periprosthetic fractures healed. CONCLUSIONS: Surgical treatment with osteosynthesis in type B post-operative fractures with a stable stem is recommended. Conservative treatment is sufficient in non-displaced type A post-operative fracture. Special attention should be paid to bone quality patients using non-cemented stems in primary surgery but especially in revision shoulder surgery.

Comparative Epidemiology of Revision Arthroplasty: Failed THA Poses Greater Clinical and Economic Burdens Than Failed TKA.

BACKGROUND: Revision THA and TKA are growing and important clinical and economic challenges. Healthcare systems tend to combine revision joint replacement procedures into a single service line, and differences between revision THA and revision TKA remain incompletely characterized. These differences carry implications for guiding care and resource allocation. We therefore evaluated epidemiologic trends associated with revision THAs and TKAs. QUESTIONS/PURPOSES: We sought to determine differences in (1) the number of patients undergoing revision TKA and THA and respective demographic trends; (2) differences in the indications for and types of revision TKA and THA; (3) differences in patient severity of illness scoring between THA and TKA; and (4) differences in resource utilization (including cost and length of stay [LOS]) between revision THA and TKA. METHODS: The Nationwide Inpatient Sample (NIS) was used to evaluate 235,857 revision THAs and 301,718 revision TKAs between October 1, 2005 and December 31, 2010. Patient characteristics, procedure information, and resource utilization were compared across revision THAs and TKAs. A revision burden (ratio of number of revisions to total number of revision and primary surgeries) was calculated for hip and knee procedures. Severity of illness scoring and cost calculations were derived from the NIS. As our study was principally descriptive, statistical analyses generally were not performed; however, owing to the large sample size available to us through this NIS analysis, even small observed differences presented are likely to be highly statistically significant. RESULTS: Revision TKAs increased by 39% (revision burden, 9.1%-9.6%) and THAs increased by 23% (revision burden, 15.4%-14.6%). Revision THAs were performed more often in older patients compared with revision TKAs. Periprosthetic joint infection (25%) and mechanical loosening (19%) were the most common reasons for revision TKA compared with dislocation (22%) and mechanical loosening (20%) for revision THA. Full (all-component) revision was more common in revision THAs (43%) than in TKAs (37%). Patients who underwent revision THA generally were sicker (> 50% major severity of illness score) than patients who underwent revision TKA (65% moderate severity of illness score). Mean LOS was longer for revision THAs than for TKAs. Mean hospitalization costs were slightly higher for revision THA (USD 24,697 +/- USD 40,489 [SD]) than revision TKA (USD 23,130 +/- USD 36,643 [SD]). Periprosthetic joint infection and periprosthetic fracture were associated with the greatest LOS and costs for revision THAs and TKAs. CONCLUSIONS: These data could prove important for healthcare systems to appropriately allocate resources to hip and knee procedures: the revision burden for THA is 52% greater than for TKA, but revision TKAs are increasing at a faster rate. Likewise, the treating clinician should understand that while both revision THAs and TKAs bear significant clinical and economic costs, patients undergoing revision THA tend to be older, sicker, and have greater costs of care.

Prevalence and risk factors for periprosthetic fracture in older recipients of total hip replacement: a cohort study.

BACKGROUND: The growing utilization of total joint replacement will increase the frequency of its complications, including periprosthetic fracture. The prevalence and risk factors of periprosthetic fracture require further study, particularly over the course of long-term follow-up. The objective of this study was to estimate the prevalence and risk factors for periprosthetic fractures occurring in recipients of total hip replacement. METHODS: We identified Medicare beneficiaries who had elective primary total hip replacement (THR) for non-fracture diagnoses between July 1995 and June 1996. We followed them using Medicare Part A claims data through 2008. We used ICD-9 codes to identify periprosthetic femoral fractures occurring from 2006-2008. We used the incidence density method to calculate the annual incidence of these fractures and Cox proportional hazards models to identify risk factors for periprosthetic fracture. We also calculated the risk of hospitalization over the subsequent year. RESULTS: Of 58,521 Medicare beneficiaries who had elective primary THR between July 1995 and June 1996, 32,463 (55%) survived until January 2006. Of these, 215 (0.7%) developed a periprosthetic femoral fracture between 2006 and 2008. The annual incidence of periprosthetic fracture among these individuals was 26 per 10,000 person-years. In the Cox model, a greater risk of periprosthetic fracture was associated with having had a total knee replacement (HR 1.82, 95% CI 1.30, 2.55) or a revision total hip replacement (HR1.40, 95% CI 0.95, 2.07) between the primary THR and 2006. Compared to those without fractures, THR recipients who sustained periprosthetic femoral fracture had three-fold higher risk of hospitalization in the subsequent year (89% vs. 27%, p<0.0001). CONCLUSION: A decade after primary THR, periprosthetic fractures occur annually in 26 per 10,000 persons and are especially frequent in those with prior total knee or revision total hip replacements.

Intra-operative periprosthetic fractures associated with press fit stems in revision total knee arthroplasty: incidence, management, and outcomes.

The purpose of this study is to report the incidence, management, and outcomes of periprosthetic fractures associated with the insertion of press-fit stems during revision total knee arthroplasty (TKA). Immediate and six week post-operative radiographs from 634 stemmed implants (307 femoral, 327 tibial) from 420 consecutive revision TKAs were reviewed. Sixteen tibial (4.9%) and 3 femoral (1%) fractures (combined incidence 3.0%) were identified. All healed uneventfully without operative intervention, with no evidence of implant loosening at a mean of 23 months (range 12 to 47 months). The technique of tightly press fitting stems into the diaphysis is associated with a small rate (3%) of periprosthetic fractures; most were non or minimally displaced, all healed uneventfully with non-operative management and were not associated with implant loosening.

Where do knee revisions for infection, fracture, and other revisions get treated?

Complicated knee revision procedures require specific expertise that may not be available across the healthcare network. Teaching hospitals appear to perform more knee revisions overall than urban or rural hospitals. We examined the location of care and payer status for all knee revisions including complex revisions (infection, periprosthetic fracture). Although only 39.7% of all primary total knee cases were performed in teaching hospitals, over half of all knee revisions were performed in teaching hospitals. Knee revision procedures, including treatment of periprosthetic infections and fractures are performed more often in teaching hospitals than in urban and rural settings combined. Reimbursement that does not match the cost of care for complex revision and infection cases may have a disproportionate impact on teaching hospitals.

What is the financial cost of treating periprosthetic hip fractures?

A total of 146 patients were identified from a prospective database of all hip fractures over a 10-year period at a United Kingdom teaching hospital. The financial costs were calculated and analysed and then compared with the money recovered through the tariff produced by Payment by Results.A total of 62% of the study group were female; mean age of 79 years; mean length of stay of 39 days.Fractures occurred around total hip replacement (THR) in 63 cases, revision THR in 27 cases and hemiarthroplasty in 56 cases. Fixation of the fracture was performed in 61 cases, revision arthroplasty in 62 cases and 23 were treated non-operatively.The mean cost of treatment was £23,469 per patient (range £615­£223,000; median £18,031). Ward costs were responsible for 80.3%, theatre costs 5.7%, implants 6.7% and investigations 7.3%. The difference in cost was statistically significant when further surgery was required (p = 0.01) and length of stay was greater than 30 days (p < 0.0001), and when compared with the money recovered by the Trust(mean £3702; p < 0.0001). These results reveal the significant economic impact of treating this group of patients at specialist centres.

The economic impact of minimally invasive total hip arthroplasty.

We compared hospital length of stay (LOS) and costs between (1) minimally invasive total hip surgery (MIS) combined with an active hip pathway (AHP) and (2) long incision total hip surgery (LIS) with a passive hip pathway (PHP). A prospective consecutive cohort of 214 MIS/AHP patients was compared to a concurrent cohort of 265 LIS/PHP patients. The MIS/AHP cohort had significantly decreased LOS (1.5 days vs. 3.8 days, P < .001) and hospital costs ($12.8 thousand vs. $16.7 thousand, P < .001). The complication rates were similar for MIS/AHP and LIS/PHP. We conclude that, compared to LIS/PHP, MIS/AHP significantly shortened LOS by an average of 2.3 days, and significantly reduced hospital costs by an average of $3.9 thousand per patient.