Best timing of bilateral total hip arthroplasty - an analysis of revision and mortality rates from the German Arthroplasty Registry (EPRD).

BACKGROUND: The burden of osteoarthritis (OA) in multiple joints is high and for patients with bilateral OA of the hip there is no clear recommendation about the indication for simultaneous (one-stage) bilateral total hip arthroplasty (THA) versus two-staged procedures. The purpose of this study was therefore to compare revision and mortality rates after different strategies of surgical timing in bilateral hip OA from the German Arthroplasty Registry (EPRD). METHODS: Since 2012 22,500 patients with bilateral THA (including 767 patients with one-staged bilateral surgery and 11,796 patients with another separate procedures within one year after first THA) are documented in the registry. The patients who underwent simultaneous bilateral THA were matched with a cohort of 767 patients who underwent the second THA between 1 and 90 days postoperatively (short interval) and another cohort of 4,602 patients with THA between 91 and 365 days postoperatively (intermediate interval). Revision for all reasons and mortality rates were recorded. Cox regression was performed to evaluate the influence of different patient characteristics. RESULTS: The cumulative 5-year revision rate for patients with simultaneous bilateral THA was 1.8% (95% CI 0.9-2.6), for patients with two-staged THA 2.3% (95% CI 1.0-3.6) in the short interval and 2.5% (95% CI 2.1-2.9) in the intermediate interval, respectively. In all three groups, patients who underwent THA in a high-volume center (≥ 500 THA per year) had a significant lower risk for revision (HR 0.687; 95% CI 0.501-0.942) compared to surgeries in a low-volume center (< 250 THA per year). There was no significant difference regarding cumulative mortality rates in the three cohorts. Higher age (HR 1.060; 95% CI 1.042-1.078) and severe comorbidities as reflected in the Elixhauser Score (HR 1.046; 95% CI 1.014-1.079) were associated with higher mortality rates after simultaneous THA. CONCLUSION: Simultaneous bilateral THA seems to be a safe procedure for younger patients with limited comorbidities who have bilateral end-stage hip OA, especially if performed in high-volume centers. LEVEL OF EVIDENCE: III.

Re-revision and mortality rate following revision total hip arthroplasty for infection.

Aims: This study compares the re-revision rate and mortality following septic and aseptic revision hip arthroplasty (rTHA) in registry data, and compares the outcomes to previously reported data. Methods: This is an observational cohort study using data from the German Arthroplasty Registry (EPRD). A total of 17,842 rTHAs were included, and the rates and cumulative incidence of hip re-revision and mortality following septic and aseptic rTHA were analyzed with seven-year follow-up. The Kaplan-Meier estimates were used to determine the re-revision rate and cumulative probability of mortality following rTHA. Results: The re-revision rate within one year after septic rTHA was 30%, and after seven years was 34%. The cumulative mortality within the first year after septic rTHA was 14%, and within seven years was 40%. After multiple previous hip revisions, the re-revision rate rose to over 40% in septic rTHA. The first six months were identified as the most critical period for the re-revision for septic rTHA. Conclusion: The risk re-revision and reinfection after septic rTHA was almost four times higher, as recorded in the ERPD, when compared to previous meta-analysis. We conclude that it is currently not possible to assume the data from single studies and meta-analysis reflects the outcomes in the 'real world'. Data presented in meta-analyses and from specialist single-centre studies do not reflect the generality of outcomes as recorded in the ERPD. The highest re-revision rates and mortality are seen in the first six months postoperatively. The optimization of perioperative care through the development of a network of high-volume specialist hospitals is likely to lead to improved outcomes for patients undergoing rTHA, especially if associated with infection.

The influence of operation time for hip hemiarthroplasty on complication rates and mortality in patients with femoral neck fracture: a retrospective data analysis.

BACKGROUND: The aim of the present study was to investigate the influence of various factors, in particular operation time, on mortality and complication rates in patients with femoral neck fractures who have undergone hip hemiarthroplasty (HHA) and to determine a cut-off value above which mortality and complication rates increase significantly. METHODS: Cases of patients with femoral neck fracture treated with HHA between 1 January 2017 and 31 December 2023 were screened for eligibility. Multiple logistic regressions were calculated to determine which factors (patient age, experience of surgeon, patient sex, ASA score, time to surgery, operation time) influenced the incidence of complications and mortality. The exact cut-off value for complications and mortality was determined using the Youden index of the ROC curve (sensitivity vs. specificity) of logistic regression. RESULTS: A total of 552 patients were considered eligible for this study. During the 90-day follow-up period after HHA, 50 deaths and 34 complications were recorded, giving a mortality rate of 9.1%, and a complication rate of 6.2%. Of the 34 complications recorded, 32.3% were infections, 14.7% dislocations, 20.7% trochanteric avulsions, 11.8% periprosthetic fractures, 11.8% nerve injuries, and 8.8% deep vein thrombosis. The odds ratio (OR) of a patient experiencing a complication is 2.2% higher for every minute increase in operation time (Exponential Beta - 1 = 0.022; p = 0.0363). The OR of a patient dying is 8.8% higher for each year increase in age (Exponential Beta - 1 = 0.088; p = 0.0007). When surgery was performed by a certified orthopaedic surgeon the mortality rate lowered by 61.5% in comparison to the surgery performed by a trainee (1 - Exponential Beta = 0.594; p = 0.0120). Male patients have a 168.7% higher OR for mortality than female patients (Exponential Beta - 1 = 1.687; p = 0.0017). Patients with an operation time of ≥ 86 min. have a 111.8% higher OR for mortality than patients with an operation time of < 86 min. (Exponential Beta - 1 = 1.118). CONCLUSION: This retrospective data analysis found that the risk of a patient experiencing a complication was 2.2% higher for every minute increase in operation time. Patients with an operation time above the cut-off of 86 min had a 111.8% higher risk of mortality than those with an operation time below the cut-off. Other influencing factors that operators should be aware of include patient age, male sex, and operator experience.

Difference in early all-cause mortality among patients having hip arthroplasty a Swedish perioperative registry study 2013-2022.

INTRODUCTION: Hip arthroplasty is a common orthopaedic procedure worldwide. There is an ongoing debate related to the fixation and anaesthesia impact on the 30-day mortality, particularly in the aging population with higher American Society of Anaesthesiology (ASA) Physical-Status. AIM: To study the 30-day all-cause mortality in patients undergoing primary hip arthroplasty, with regards to the impact of age, ASA-class, anaesthesia techniques, indication for surgery and fixation techniques. MATERIALS AND METHODS: Perioperative data for primary hip arthroplasty procedures for osteoarthritis and hip fractures registered in the Swedish Perioperative Registry (SPOR) between 2013 and June 2022 were collected. Binary logistic regressions were performed to assess the impact of age, ASA-class, anaesthetic technique, indication for surgery and fixation on odds ratio for 30-day mortality in Sweden. RESULTS: In total, 79,114 patients, 49,565 with osteoarthritis and 29,549 with hip fractures were included in the main study cohort. Mortality was significantly higher among hip fracture patients compared with osteoarthritis, cumulative 8.2% versus 0.1% at 30-days respectively (p < 0.001). Age above 80 years (OR3.7), ASA 3-5 (OR3.3) and surgery for hip fracture (OR 21.5) were associated with significantly higher odds ratio, while hybrid fixation was associated with a significantly lower odds ratio (OR0.4) of 30-day mortality. In the same model, for the subgroups of osteoarthritis and hip fracture, only age (OR 3.7) and ASA-class (OR 3.3) had significant impact, increasing the odds ratio for 30-day mortality. Hemi arthroplasty was commonly used among the hip fracture patients 20.453 (69.2%), and associated with a significantly higher odds ratio for all-cause 30-day mortality as compared to total hip arthroplasty when adjusting for age and ASA-class and fixation 2.3 (95%CI 1.9-2.3, p < 0.001). CONCLUSIONS: All-cause 30-day mortality associated with arthroplasty differed significantly between the two cohorts, hip fracture, and osteoarthritis (8.2% and 0.1% respectively) and mortality expectedly increased with age and higher ASA-class. Anaesthetic method and cement-fixation did not impact the odds ratio for all-cause 30-day mortality after adjustment for age and ASA-class.

Association between inflammation-based prognostic markers and mortality after hip replacement.

We aimed to evaluate the association between inflammation-based prognostic markers and mortality after hip replacement. From March 2010 to June 2020, we identified 5,369 consecutive adult patients undergoing hip replacement with C-reactive protein (CRP), albumin, and complete blood count measured within six months before surgery. Receiver operating characteristic (ROC) curves were generated to evaluate predictabilities and estimate thresholds of CRP-to-albumin ratio (CAR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR). Patients were divided according to threshold, and mortality risk was compared. The primary outcome was one-year mortality, and overall mortality was also analyzed. One-year mortality was 2.9%. Receiver operating characteristics analysis revealed areas under the curve of 0.838, 0.832, 0.701, and 0.732 for CAR, NLR, PLR, and modified Glasgow Prognostic Score, respectively. The estimated thresholds were 2.10, 3.16, and 11.77 for CAR, NLR, and PLR, respectively. According to the estimated threshold, high CAR and NLR were associated with higher one-year mortality after adjustment (1.0% vs. 11.7%; HR = 2.16; 95% CI 1.32-3.52; p = 0.002 for CAR and 0.8% vs. 9.6%; HR = 2.05; 95% CI 1.24-3.39; p = 0.01 for NLR), but PLR did not show a significant mortality increase (1.4% vs. 7.4%; HR = 1.12; 95% CI 0.77-1.63; p = 0.57). Our study demonstrated associations of preoperative levels of CAR and NLR with postoperative mortality in patients undergoing hip replacement. Our findings may be helpful in predicting mortality in patients undergoing hip replacement.

Unseen Threefold Mortality After the First Ten Days in Hemodialysis Patients Following Joint Arthroplasty: A Nationwide Retrospective Cohort Study of 1,287 Arthroplasty Patients on Hemodialysis.

BACKGROUND: The study addresses the growing number of hemodialysis (HD) patients undergoing joint arthroplasty, who are at higher risk of complications and mortality. Previous research has often overlooked deaths after discharge. This study aimed to examine early outcomes in a large nationwide cohort of patients who underwent arthroplasty for elective and fracture-related reasons. METHODS: Between 2016 and 2022, a study was conducted using the e-Nabiz database of the Türkiye Ministry of Health, focusing on patients aged 18 years and above who underwent elective or fracture-related arthroplasty. This study included 1,287 patients reliant on dialysis who underwent total hip arthroplasty, total knee arthroplasty, or hemiarthroplasty (HA), with 7.7% of them receiving dialysis for the first time. Propensity score matching was used to create an equally sized group of non-dialysis-dependent patients, ensuring demographic balance in terms of age, sex, a comorbidity index, and surgery type. The primary objective was to compare mortality rates 10, 30, and 90 days after arthroplasty. RESULTS: The first-time dialysis patients who underwent HA had significantly higher 30- and 90-day mortality rates compared to the chronic dialysis group (P = .040 and P < .001, respectively). Also, the HD patients consistently exhibited higher 90-day mortality rates across all surgery types. With total knee arthroplasty, HD patients had a mortality rate of 8.7%, in stark contrast to 0% among non-HD patients (P < .001). Similarly, with total hip arthroplasty, HD patients had a 12% mortality rate, while non-HD patients had a markedly lower rate of 2.7% (P = .008). In the case of HA, HD patients had a significantly elevated 90-day mortality rate of 31.9%, in contrast to 17.1% among non-HD patients (P < .001). CONCLUSIONS: Joint arthroplasty has higher rates of mortality and complications among HD patients. Surgical decisions must be based on patients' overall health, necessitating collaboration among specialists. These patients should be closely monitored.

Surgery Within 24 Hours Reduces Mortality and General Complication Rates in Patients Who Have Periprosthetic Femoral Fractures at the Hip.

BACKGROUND: In patients who have hip fractures, treatment within 24 hours reduces mortality and complication rates. A similar relationship can be assumed for patients who have hip periprosthetic femoral fractures (PPFs) owing to the similar baseline characteristics of the patient populations. This monocentric retrospective study aimed to compare the complication and mortality rates in patients who had hip PPF treated within and after 24 hours. METHODS: In total, 350 consecutive patients who had hip PPF in a maximum-care arthroplasty and trauma center between 2006 and 2020 were retrospectively evaluated. The cases were divided into 2 groups using a time to surgery (TTS) of 24 hours as the cutoff value. The primary outcome variables were operative and general complications as well as mortalities within 1 year. RESULTS: Overall, the mean TTS was 1.4 days, and the 1-year mortality was 14.6%. The TTS ≤ 24 hours (n = 166) and TTS > 24 hours (n = 184) groups were comparable in terms of baseline characteristics and comorbidities. Surgical complications were equally frequent in the 2 groups (16.3 versus 15.2%, P = .883). General complications occurred significantly more often in the late patient care group (11.4 versus 28.3%, P < .001). In addition, the 30-day mortality (0.6 versus 5.5%, P = .012), and 1-year mortality (8.3 versus 20.5%, P = .003) rates significantly increased in patients who had TTS > 24 hours. Cox regression analysis yielded a hazard ratio of 4.385 (P < .001) for the TTS > 24 hours group. CONCLUSIONS: Prompt treatment is required for patients who have hip PPF to reduce mortality and overall complications.

Impact of surgical timing and type of operative procedure on outcomes in periprosthetic hip fractures: an observational study at an NHS trust centre in the UK.

PURPOSE: There is a global trend of increased periprosthetic fractures due to the growing number of arthroplasty procedures. The present study assessed the impact of factors such as time to surgery and type of surgery on the outcomes, which have been seldom evaluated for periprosthetic fractures. METHODS: An observational study was conducted on consecutive 87 patients within an NHS district hospital trust in the UK. Patients who underwent a complete hip replacement prior to the fracture, received fixation therapy, or underwent revision surgery within the specified time were screened. Patients were grouped in two ways: based on time to surgery and based on surgery type. Logistic regression models were performed to assess for statistically significant differences in post-operative complication, 30-day, and 1-year mortality rates between groups, whilst adjusting for age, gender, and ASA grade. RESULTS: Forty-one patients underwent open reduction and internal fixation (ORIF), 29 patients underwent revision arthroplasty, and 17 patients were subjected to both, ORIF and revision arthroplasty. Sixty of the 87 patients were operated on > 48 h of injury. The median hospital stay was significantly lower in the ORIF plus revision arthroplasty group, versus other surgical groups (p < 0.05) whilst it was significantly higher in the group of patients who underwent surgery after 48 h of injury (p < 0.05). Numerically higher mortality was noted in the revision arthroplasty group (31.03%, p > 0.05). The group that was operated after 48 h of injury showed greater mortality but was comparable to the other group (25% vs. 14.81%, p > 0.05). For post-operative complications, none of the variables were significantly predictive (p > 0.05). However, for 30-day mortality, ASA grade (p = 0.04) and intra-operative complications (p = 0.0001) were significantly predictive. Additionally, for 1-year mortality, ASA grade (p = 0.004) was noted to be significantly predictive. CONCLUSION: Revision and delayed periprosthetic fracture management (> 48 h after injury) group showed a numerically greater mortality risk; however, this finding was not statistically significant. ASA grading at baseline is predictive of mortality for periprosthetic fractures.

Costs of Joint Replacement in Osteoarthritis: A Study Using the National Joint Registry and Clinical Practice Research Datalink Data Sets.

OBJECTIVE: To estimate the costs of primary hip and knee replacement in individuals with osteoarthritis up to 2 years postsurgery, compare costs before and after the surgery, and identify predictors of hospital costs. METHODS: Patients age ≥18 years with primary planned hip or knee replacements and osteoarthritis in England between 2008 and 2016 were identified from the National Joint Registry and linked with Hospital Episode Statistics data containing inpatient episodes. Primary care data linked with hospital outpatient records were also used to identify patients age ≥18 years with primary hip or knee replacements between 2008 and 2016. All health care resource use was valued using 2016/2017 costs, and nonparametric censoring methods were used to estimate total 1-year and 2-year costs. RESULTS: We identified 854,866 individuals undergoing hip or knee replacement. The mean censor-adjusted 1-year hospitalization costs for hip and knee replacement were £7,827 (95% confidence interval [95% CI] 7,813, 7,842) and £7,805 (95% CI 7,790, 7,818), respectively. Complications and revisions were associated with up to a 3-fold increase in 1-year hospitalization costs. The censor-adjusted 2-year costs were £9,258 (95% CI 9,233, 9,280) and £9,452 (95% CI 9,430, 9,475) for hip and knee replacement, respectively. Adding primary and outpatient care, the mean total hip and knee replacement 2-year costs were £11,987 and £12,578, respectively. CONCLUSION: There are significant costs following joint replacement. Revisions and complications accounted for considerable costs and there is a significant incentive to identify best approaches to reduce these.

No increased mortality after total hip arthroplasty in patients with a history of pediatric hip disease: a matched, population-based cohort study on 4,043 patients.

Background and purpose - Patients with pediatric hip diseases are more comorbid than the general population and at risk of premature, secondary osteoarthritis, often leading to total hip arthroplasty (THA). We investigated whether THA confers an increased mortality in this cohort.Patients and methods - We identified 4,043 patients with a history of Legg-Calvé-Perthes disease (LCPD), slipped capital femoral epiphysis (SCFE), or developmental dysplasia of the hip (DDH) in the Swedish Hip Arthroplasty Register (SHAR) between 1992 and 2012. For each patient, we matched 5 controls from the general population for age, sex, and place of residence, and acquired information on all participants' socioeconomic background and comorbidities. Mortality after THA was estimated according to Kaplan-Meier, and Cox proportional hazard models were fitted to estimate adjusted hazard ratios (HRs) for the risk of death.Results - Compared with unexposed individuals, patients exposed to a THA due to pediatric hip disease had lower incomes, lower educational levels, and a higher degree of comorbidity but a statistically non-significant attenuation of 90-day mortality (HR 0.9; 95% CI 0.4-2.0) and a lower risk of overall mortality (HR 0.8; CI 0.7-0.9).Interpretation - Patients exposed to THA due to a history of pediatric hip disease have a slightly lower mortality than unexposed individuals. THA seems not to confer increased mortality risks, even in these specific patients with numerous risk factors.

A comparison of comorbidity measures for predicting mortality after elective hip and knee replacement: A cohort study of data from the National Joint Registry in England and Wales.

BACKGROUND: The risk of mortality following elective total hip (THR) and knee replacements (KR) may be influenced by patients' pre-existing comorbidities. There are a variety of scores derived from individual comorbidities that can be used in an attempt to quantify this. The aims of this study were to a) identify which comorbidity score best predicts risk of mortality within 90 days or b) determine which comorbidity score best predicts risk of mortality at other relevant timepoints (30, 45, 120 and 365 days). PATIENTS AND METHODS: We linked data from the National Joint Registry (NJR) on primary elective hip and knee replacements performed between 2011-2015 with pre-existing conditions recorded in the Hospital Episodes Statistics. We derived comorbidity scores (Charlson Comorbidity Index-CCI, Elixhauser, Hospital Frailty Risk Score-HFRS). We used binary logistic regression models of all-cause mortality within 90-days and within 30, 45, 120 and 365-days of the primary operation using, adjusted for age and gender. We compared the performance of these models in predicting all-cause mortality using the area under the Receiver-operator characteristics curve (AUROC) and the Index of Prediction Accuracy (IPA). RESULTS: We included 276,594 elective primary THRs and 338,287 elective primary KRs for any indication. Mortality within 90-days was 0.34% (N = 939) after THR and 0.26% (N = 865) after KR. The AUROC for the CCI and Elixhauser scores in models of mortality ranged from 0.78-0.81 after THR and KR, which slightly outperformed models with ASA grade (AUROC = 0.77-0.78). HFRS performed similarly to ASA grade (AUROC = 0.76-0.78). The inclusion of comorbidities prior to the primary operation offers no improvement beyond models with comorbidities at the time of the primary. The discriminative ability of all prediction models was best for mortality within 30 days and worst for mortality within 365 days. CONCLUSIONS: Comorbidity scores add little improvement beyond simpler models with age, gender and ASA grade for predicting mortality within one year after elective hip or knee replacement. The additional patient-specific information required to construct comorbidity scores must be balanced against their prediction gain when considering their utility.

Fatal outcome and intensive care unit admission after total hip and knee arthroplasty: An analytic of preoperative frailty and comorbidities.

BACKGROUND: With increasing demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA), a higher percentage of patients are identified with comorbidities that might increase the risk of complications. We aimed to elucidate the preoperative characteristics of patients with a fatal outcome or admission to the Intensive Care Unit (ICU) within 90 days after THA or TKA. We arbitrarily hypothesized that more than 50% of those patients would be frail. METHODS: This is a register based, explorative study including patients undergoing elective, unilateral, primary THA or TKA in the Capital Region of Denmark from 2010 to 2017, and who subsequently died or were admitted to the ICU within 90 days. The modified Frailty Index (mFI) was calculated from the medical records, and a score of ≥0.36 defined frailty. RESULTS: A total of 33,758 patients underwent THA or TKA, and 284 patients (0.8%) died or were admitted to the ICU within 90 days. Fifty-seven patients (20%) were frail (95% CI 16.2-25.7%). The most common comorbidities were hypertension (63%) and pulmonary diseases (32%), and 56% used walking aids. Two or more comorbidities were present in 65% of patients, and 14% had no comorbidities at all. CONCLUSION: Only 20% of patients with a fatal outcome or ICU admission after elective THA or TKA could be categorized as frail based on the mFI. Further studies with a prospective design are needed to clarify the mFI as a risk stratification tool in elderly multimorbid patients undergoing elective arthroplasty surgery.

Impact of socioeconomic status on the 90- and 365-day rate of revision and mortality after primary total hip arthroplasty: a cohort study based on 103,901 patients with osteoarthritis from national databases in Denmark.

Background and purpose - Socioeconomic inequality in health is recognized as an important public health issue. We examined whether socioeconomic status (SES) is associated with revision and mortality rates after total hip arthroplasty (THA) within 90 and 365 days.Patients and methods - We obtained SES markers (cohabitation, education, income, and liquid assets) on 103,901 THA patients from Danish health registers (year 1995-2017). The outcomes were any revision (all revisions), specified revision (due to infection, fracture, or dislocation), and mortality. We used Cox regression analysis to estimate adjusted hazard ratio (aHR) of each outcome with 95% confidence interval (CI) for each SES marker.Results - Within 90 days, the aHR for any revision was 1.3 (95% CI 1.1-1.4) for patients living alone vs. cohabiting. The aHR was 2.0 (CI 1.4-2.6) for low-income vs. high-income among patients < 65 years. The aHR was 1.2 (CI 0.9-1.7) for low liquid assets among patients > 65 years. Results were consistent for any revision within 365 days as well as for revisions due to infection, fracture, and dislocation. The aHR for mortality was 1.4 (CI 1.2-1.6) within 90 days and 1.3 (CI 1.2-1.5) within 365 days for patients living alone vs. cohabiting. Low education, low income, and low liquid assets were associated with increased mortality rate within both 90 and 365 days.Interpretation - Our results suggest that living alone, low income, and low liquid assets were associated with increased revision and mortality up to 365 days after THA surgery. Optimizing medical conditions prior to surgery and implementing different post-THA support strategies with a focus on vulnerable patients may reduce complications associated with inequality.

Comparison of Peripheral Nerve Block and Spinal Anesthesia in Terms of Postoperative Mortality and Walking Ability in Elderly Hip Fracture Patients - A Retrospective, Propensity-Score Matched Study.

PURPOSE: To compare the effects of peripheral nerve block (PNB) and spinal anesthesia (SA) on one-year mortality and walking ability of elderly hip fracture patients after hip arthroplasty. METHODS: Patients ≥65 years who underwent unilateral hip arthroplasty due to femoral neck fracture, using either PNB or SA from 2014 to 2019, were included. Demographic data, comorbidities, and results of preoperative screening were retrospectively collected. Propensity score matching (PSM) was performed in a ratio of 1:1 for PNB and SA groups. The primary outcomes were 30-day, 90-day, and one-year mortality. Secondary outcomes included walking ability in the first postoperative year, major complications, length of stay, and the cost of hospitalization. Survival analysis was performed using Kaplan-Meier method. RESULTS: Three hundred and sixteen patients were included, of whom 200 received SA and 116 received PNB. Eighty-nine patients in each group were matched after PSM. Patients in the PNB group showed significantly lower risks of death in 30 days (2.2% vs 10.1%, P=0.029) and 90 days (3.4% vs 12.4%, P=0.026) after hip arthroplasty, when compared to the SA group. There was no significant difference in one-year mortality, walking ability, major complications, and length of stay. Higher hospitalization cost was found in the PNB group (53,828.21 CNY vs 59,278.83 CNY, P=0.024). One-year accumulated survival rate was higher in the PNB group without reaching a significant level. CONCLUSION: PNB was related to lower 30- and 90-day mortality but higher hospitalization cost in elderly hip fracture patients after hip arthroplasty. However, the anesthesia types were not associated with one-year mortality, one-year walking ability, major complications, and length of stay.

Minimum 15-year results of metasul 28-mm metal-on-metal total hip arthroplasty in patients younger than 50 years of age.

BACKGROUND: Some propitious mid- and long-term studies had been reported for MoM bearings; however, most studies have addressed specific patient groups rather than younger, active patients, who probably represent the most suitable population for investigations on wear and osteolysis. The purpose of this study to evaluate the long-term results of second-generation metal-on-metal cementless total hip arthroplasty (THA) in patients aged <50 years. METHODS: From December 1997 to January 2004, primary THA using a metal-on-metal bearing cementless implant was performed in 63 patients (72 hips) aged <50 years. The mean follow-up duration was 18.6 (range, 15.9-22.1) years, and the mean age at initial operation was 39 (range, 22-49) years. Clinical results, complications, survivorship, osteolysis, and aseptic loosening were evaluated. RESULTS: The mean Harris hip score and Western Ontario and McMaster Universities Arthritis Index scores were improved from 57.8 (range, 28-69) points and 73.4 (range, 63-94) points preoperatively to 91.7 (range, 80-100) points and 25.5 points (range, 17-38) points, respectively, at the last follow-up. Osteolysis lesions were found in 12 hips (acetabulum, 6 and femur, 6). The notching occurred on the femoral stem neck occurred in 12 hips. The mean serum cobalt and chromium concentrations were 2.3 (range, 0.2-10.6) µg/L and 1.7 (range, 0.4-8.1) µg/L, respectively, at a mean follow-up of 12.7 years in 32 patients (50.1%). The Kaplan-Meier survivorship curve analysis with revision for any reason as the endpoint revealed that 93.1% survived at 18.6 years' follow-up. CONCLUSIONS: Second-generation metal-on-metal cementless THA was found to produce satisfactory clinical and radiographic results with a low revision rate for osteolysis and aseptic loosening in patients aged less than 50 years.

Prediction of 90-day mortality after total hip arthroplasty.

AIMS: To develop and externally validate a parsimonious statistical prediction model of 90-day mortality after elective total hip arthroplasty (THA), and to provide a web calculator for clinical usage. METHODS: We included 53,099 patients with cemented THA due to osteoarthritis from the Swedish Hip Arthroplasty Registry for model derivation and internal validation, as well as 125,428 patients from England and Wales recorded in the National Joint Register for England, Wales, Northern Ireland, the Isle of Man, and the States of Guernsey (NJR) for external model validation. A model was developed using a bootstrap ranking procedure with a least absolute shrinkage and selection operator (LASSO) logistic regression model combined with piecewise linear regression. Discriminative ability was evaluated by the area under the receiver operating characteristic curve (AUC). Calibration belt plots were used to assess model calibration. RESULTS: A main effects model combining age, sex, American Society for Anesthesiologists (ASA) class, the presence of cancer, diseases of the central nervous system, kidney disease, and diagnosed obesity had good discrimination, both internally (AUC = 0.78, 95% confidence interval (CI) 0.75 to 0.81) and externally (AUC = 0.75, 95% CI 0.73 to 0.76). This model was superior to traditional models based on the Charlson (AUC = 0.66, 95% CI 0.62 to 0.70) and Elixhauser (AUC = 0.64, 95% CI 0.59 to 0.68) comorbidity indices. The model was well calibrated for predicted probabilities up to 5%. CONCLUSION: We developed a parsimonious model that may facilitate individualized risk assessment prior to one of the most common surgical interventions. We have published a web calculator to aid clinical decision-making. Cite this article: Bone Joint J 2021;103-B(3):469-478.

International variation in distribution of ASA class in patients undergoing total hip arthroplasty and its influence on mortality: data from an international consortium of arthroplasty registries.

Background and purpose - A challenge comparing outcomes from total hip arthroplasty between countries is variation in preoperative characteristics, particularly comorbidity. Therefore, we investigated between-country variation in comorbidity in patients based on ASA class distribution, and determined any variation of ASA class to mortality risk between countries.Patients and methods - All arthroplasty registries collecting ASA class and mortality data in patients with elective primary THAs performed 2012-2016 were identified. Survival analyses of the influence of ASA class on 1-year mortality were performed by individual registries, followed by meta-analysis of aggregated data.Results - 6 national registries and 1 US healthcare organization registry with 418,916 THAs were included. There was substantial variation in the proportion of ASA class III/IV, ranging from 14% in the Netherlands to 39% in Finland. Overall, 1-year mortality was 0.93% (95% CI 0.87-1.01) and increased from 0.2% in ASA class I to 8.9% in class IV. The association between ASA class and mortality measured by hazard ratios (HR) was strong in all registries even after adjustment for age and sex, which reduced them by half in all registries. Combined adjusted HRs were 2.0, 6.1, and 22 for ASA class II-IV vs. I, respectively. Associations were moderately heterogeneous across registries.Interpretation - We observed large variation in ASA class distribution between registries, possibly explained by differences in background morbidity and/or international variation in access to surgery. The similar, strong mortality trends by ASA class between countries enhance the relevance of its use as an indicator of comorbidity in international registry studies.

Similar early mortality risk after cemented compared with cementless total hip arthroplasty for primary osteoarthritis: data from 188,606 surgeries in the Nordic Arthroplasty Register Association database.

Background and purpose - Current literature indicates no difference in 90-day mortality after cemented compared with cementless total hip arthroplasty (THA). However, previous studies are hampered by potential selection bias and suboptimal adjustment for comorbidity confounding. Therefore, we examined the comorbidity-adjusted mortality up to 90 days after cemented compared with cementless THA performed due to osteoarthritis.Patients and methods - Using the Nordic Arthroplasty Register Association database, 2005-2013, we included 108,572 cemented and 80,034 cementless THA due to osteoarthritis. We calculated the Charlson comorbidity index of each patient based on data from national patient registers. The Kaplan-Meier method was used to estimate unadjusted all-cause mortality. Cox regression was used to estimate hazard ratios (HR) with 95% confidence intervals (CI) for 14, 30-, and 90-day mortality comparing cemented with cementless THA, adjusting for age, sex, comorbidity, nation, and year of surgery.Results - Cumulative all-cause mortality within 90 days was 0.41% (CI 0.37-0.46) after cemented and 0.26% (CI 0.22-0.30) after cementless THA. The adjusted HR for cemented vs. cementless fixation was 0.97 (CI 0.79-1.2), and similar risk estimates were obtained for mortality within 14 (adjusted HR 0.91 [CI 0.64-1.3]) and 30 days (adjusted HR 0.94 [CI 0.71-1.3]). We found no clinically relevant differences in mortality between cemented and cementless THA in analyses stratified by age, sex, Charlson comorbidity index, or year of surgery.Interpretation - After adjustment for comorbidity as an important confounder, we observed similar early mortality between the 2 fixation techniques.

Outcomes of hip arthroplasty with concomitant hardware removal: influence of the type of implant retrieved and impact of positive intraoperative cultures.

INTRODUCTION: The impact of residual internal fixation devices on subsequent procedures about the hip has not been clearly well defined. The objective of the current study is to evaluate the outcome of hip arthroplasty after hardware retrieval as a one-stage replacement, to analyze possible differences related to the type of removed implant, and to assess the impact of unexpected intraoperative cultures during implant retrieval. MATERIALS AND METHODS: We present a retrospective study including all those cases undergoing hip arthroplasty with concomitant hardware removal (cannulated screws, intramedullary nail, or dynamic hip screw) from 2005 to 2018. We evaluated demographics, intraoperative cultures, early infection rate, and other complications. RESULTS: A total of 55 cases were included in the study. The median time between the implant surgery and the hip arthroplasty was 113 days. The removed devices included 6 cannulated screws, 34 intramedullary nails, and 15 dynamic hip screws. Up to 74.5% of the failed osteosynthesis belonged to intertrochanteric femoral fractures. Dislocation rate was 9.1% (1.8% requiring revision surgery), 25.5% of the cases needed further new surgeries after the hip arthroplasty, and 49.1% died during the follow-up period. Any-cause revision surgery and mortality rates were significantly increased after intramedullary nail removal. Intraoperative cultures were performed in 46 cases, and in 9 (16.4%), there was bacterial contamination: 6 cases (10.9%) presented one single positive culture and 3 (5.5%) presented ≥ 2 positive cultures for the same microorganism. A total of five cases (9.1%) presented early prosthetic joint infection that required debridement. None of these five cases had presented positive cultures at the implant removal. CONCLUSION: According to our results, hip arthroplasty with concomitant hardware removal is related to a high 5-year mortality rate, mainly when intramedullary nail is retrieved. Whereas a high risk of early prosthetic joint infection is associated, it seems not to be related to the elevated presence of unexpected positive cultures.

Postoperative Morbidity and Mortality in Diabetic Patients After Fast-Track Hip and Knee Arthroplasty: A Prospective Follow-up Cohort of 36,762 Procedures.

BACKGROUND: Diabetes increases the risk of adverse outcomes in surgical procedures, including total hip and knee arthroplasty (THA/TKA), and the prevalence of diabetic patients undergoing these procedures is high, ranging from approximately 8% to 20%. However, there is still a need to clarify the role of diabetes and antihyperglycemic treatment in a fast-track THA/TKA setting, which otherwise may decrease morbidity. Consequently, we investigated the association between diabetes and antihyperglycemic treatment on length of stay (LOS) and complications following fast-track THA/TKA within a multicenter fast-track collaboration. METHODS: We used an observational study design on data from a prospective multicenter fast-track collaboration on unselected elective primary THA/TKA from 2010 to 2017. Complete follow-up (>99%) was achieved through The Danish National Patient Registry, antihyperglycemic treatment established through the Danish National Database of Reimbursed Prescriptions and types of complications leading to LOS >4 days, 90-day readmission or mortality obtained by scrutinizing health records and discharge summaries. Patients were categorized as nondiabetic and if diabetic into insulin-, orally, and dietary-treated diabetic patients. RESULTS: A total of 36,762 procedures were included, of which 837 (2.3%) had insulin-treated diabetes, 2615 (7.1%) orally treated diabetes, and 566 (1.5%) dietary-treated diabetes. Overall median LOS was 2 (interquartile range [IQR]: 1-3) days, and mean LOS was 2.4 (standard deviation [SD], 2.5) days. The proportion of patients with LOS >4 days was 6.0% for nondiabetic patients, 14.7% for insulin-treated, 9.4% for orally treated, and 9.5% for dietary-treated diabetic patients. Pharmacologically treated diabetes (versus nondiabetes) was independently associated with increased odds of LOS >4 days (insulin-treated: odds ratio [OR], 2.2 [99.6% confidence interval {CI}, 1.3-3.7], P < .001; orally treated: OR, 1.5 [99.6% CI, 1.0-2.1]; P = .002). Insulin-treated diabetes was independently associated with increased odds of "diabetes-related" morbidity (OR, 2.3 [99.6% CI, 1.2-4.2]; P < .001). Diabetic patients had increased renal complications regardless of antihyperglycemic treatment, but only insulin-treated patients suffered significantly more cardiac complications than nondiabetic patients. There was no increase in periprosthetic joint infections or mortality associated with diabetes. CONCLUSIONS: Patients with pharmacologically treated diabetes undergoing fast-track THA/TKA were at increased odds of LOS >4 days. Although complication rates were low, patients with insulin-treated diabetes were at increased odds of postoperative complications compared to nondiabetic patients and to their orally treated counterparts. Further investigation into the pathogenesis of postoperative complications differentiated by antihyperglycemic treatment is needed.