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.

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.

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.

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.

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 .

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.

The clinical and economic burden of proximal femur periprosthetic fractures.

BACKGROUND: The number of hip replacements is constantly and progressively increasing, resulting in an increase in periprosthetic fractures. The main aim of this study is to analyze costs and outcomes of surgical treatment for those fractures. MATERIALS AND METHODS: A retrospective study was performed on periprosthetic proximal femur fracture presented a single-level I trauma center. Medical records were reviewed in terms of demographic data, diagnosis (according to Vancouver classification), type of surgical treatment, hospitalization length and follow-up. Patients were interviewed about number of consultations after discharge, medications and physiotherapy sessions. Clinical outcome was evaluated with WOMAC score at the last follow-up, and patient health status was evaluated with the EQ5D5L score pre-trauma and at the last follow-up. Patients were divided into two groups according to surgical treatment: reduction and internal fixation alone and revision plus fixation. A further group was also considered: patients underwent a Girdlestone procedure. Global costs for each group were calculated. RESULTS: We initially recruited 117 patients, 17 of them were lost at follow-up. Furthermore, 19 patients (19%) died during the follow-up, and 81 of them were therefore included in the study. Mean follow-up was 26.5 months. Mean postoperative WOMAC score was 39.44, and EQ5D5L score was 9.12 for the preoperative period and 12.35 at the last follow-up. A significant worsening of clinical conditions was found comparing the period before fracture to the last follow-up (p < 0.01). Quality of life after surgery resulted to be poor or fair in 40% of the patients at a mean follow-up of 26.5 months. No significant differences between groups were found according to patients' health status. Mean global costs for mayor surgeries were 18,822 Euros; mean costs for fixation alone were 17,298 Euros while for fixation and revision were 20,966 Euros, but no statistically difference was found between these two groups. Mean cost for Girdlestone group was 12,664 Euros. CONCLUSIONS: In proximal femur periprosthetic fractures, either fixation or revision plus fixation presents high costs but patients' postoperative quality of life is poor.

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.

Computed tomography for managing periprosthetic femoral fractures. A retrospective analysis.

BACKGROUND: Periprosthetic fractures (PPF) present a common cause for revision surgery after arthroplasty. The choice of performing either an osteosynthesis or revision arthroplasty depends on the orthopedic implant anchored and loosening. Standard diagnostics include x-ray imaging. CT is usually performed to confirm implant loosening in case of ambiguous diagnosis on standard x-ray imaging. This study aimed to examine the role of CT as a diagnostic modality and its implications for treatment planning and outcome. METHODS: Patients treated for PPF from January 2010 to February 2018 were included. X-ray and CT reports were analyzed to assess implant loosening. The planning for surgery and the final surgical treatment were evaluated. In addition, patient characteristics were analyzed and compared between patients with and without additional CT as a preoperative diagnostic procedure. RESULTS: Seventy-five patients were eligible for the study. X-ray imaging was performed in 90.7% of cases. CT was performed in 60% of the cases as part of the preoperative diagnostic. A clear statement on implant stability or loosening could not be made in 69.1% after X-ray imaging and in 84.4% following CT imaging. Revision arthroplasty for loosened femoral prosthesis components was necessary in 40% of cases. No difference could be determined comparing patients with X-ray imaging to those with X-ray and additional CT. In both groups, operative treatment did not deviate from the preoperative planning. DISCUSSION: In two thirds of the conventional radiographic findings, no reliable evaluation of implant loosening was possible in femoral PPFs. Intriguingly, additional CT did not improve the evaluation of implant loosening. Nonetheless, CT scans are often performed if loosening assessment is unclear on regular radiographs. This fact can explain the bias CT results in comparison to regular radiography. However, software-supported CT diagnosis could help to adequately answer the question of loosened implants in PPF in the near future. Since the diagnosis of fracture and their morphology assessment is currently adequately performed using X-rays, CT shall not be considered as the gold standard.

The national burden of periprosthetic hip fractures in the US: costs and risk factors for hospital readmission.

INTRODUCTION: Periprosthetic hip fractures (PPFX) are serious complications that result in increased morbidity, mortality and healthcare costs. Decreasing hospital readmissions has been a recent healthcare focus, but little is known about the overall costs associated with PPFX or the risk factors associated with readmissions. We investigated patient demographics, treatment types, 30- and 90-day readmission rates, direct costs, and patient risk factors associated with PPFX readmission. METHODS: We used the 2013 Nationwide Readmissions Database to select patients who underwent total hip arthroplasty (THA), revision THA, and PPFX treated with open reduction internal fixation (ORIF) or revision THA. Survival analysis was used to evaluate the 90-day all-cause hospital readmission rate, and risk factors were identified using a Cox proportional hazards model, adjusting for patient and hospital characteristics. RESULTS: We identified 1269 patients with PPFX treated with ORIF and 3254 treated with revision THA. 90-day readmissions were 20.9% and 27.3%, respectively. Patients with PPFX were older, female, and had multiple medical comorbidities. Patient factors associated with increased risk of readmission include: age; comorbidities; and discharge to skilled nursing facility; Medicare or Medicaid insurance. Hospital factors associated with increased risk of readmission include: large hospitals; nonprofits; metropolitan and teaching hospitals. The cost of readmission for PPFX treated with ORIF was $17,206 and revision THA was $16,504. DISCUSSION: Periprosthetic hip fractures have high rates of hospital readmission, implying a significant burden to the healthcare system. Identifying risk factors is an important step towards identifying treatment pathways that can improve outcomes.

The "Bundle Busters": Incidence and Costs of Postacute Complications Following Total Joint Arthroplasty.

BACKGROUND: Recently, a bundled payment model was implemented in the United States to improve quality and reduce costs. While hospitals may be rewarded for lowering costs, they may be financially exposed by high cost complications, the so-called bundle busters. We aimed at determining the incidence, etiology, and costs of postacute complications after total joint arthroplasty (TJA). METHODS: A retrospective study was conducted using a prospectively collected database of patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) from January 2015 to April 2016. Nurse navigators performed postoperative surveillance to identify patients with complications and unplanned clinical events in the 90-day postoperative period. This was combined with episode-of-care costs provided by third-party payers to derive the mean and per capita costs of postacute complications and clinical events. RESULTS: Among 3018 THA and 5389 TKA patients, 3.35% of THA and 2.62% of TKA patients sought emergency department or urgent care services, 2.62% of THA and 3.69% of TKA patients required hospital readmission, and 3.99% of TKA patients required manipulation. Joint-related complications were more common following THA, whereas medical complications were more frequent after TKA. The most costly complications after THA were periprosthetic fracture, dislocation, and myocardial infarction, compared to deep infection, myocardial infarction, and pulmonary embolism after TKA. CONCLUSION: Joint-related complications were among the most costly events after TJA, and given their higher incidence after THA, had a larger impact on per capita costs. Medical complications were more common after TKA and more costly. Despite these events, postacute complications made up less than 5% of the total 90-day costs of TJA.

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.

Implant options for the treatment of intertrochanteric fractures of the hip: rationale, evidence, and recommendations.

AIMS: The aim of this paper is to review the evidence relating to the anatomy of the proximal femur, the geometry of the fracture and the characteristics of implants and methods of fixation of intertrochanteric fractures of the hip. MATERIALS AND METHODS: Relevant papers were identified from appropriate clinical databases and a narrative review was undertaken. RESULTS: Stable, unstable, and subtrochanteric intertrochanteric fractures vary widely in their anatomical and biomechanical characteristics, as do the implants used for their fixation. The optimal choice of implant addresses the stability of the fracture and affects the outcome. CONCLUSION: The treatment of intertrochanteric fractures of the hip has evolved along with changes in the design of the implants used to fix them, but there remains conflicting evidence to guide the choice of implant. We advocate fixation of 31A1 fractures with a sliding hip screw and all others with an intramedullary device. Cite this article: Bone Joint J 2017;99-B:128-33.