Risk of Aseptic Revision and Periprosthetic Fracture Following Bipolar Versus Unipolar Hemiarthroplasty.

Hemiarthroplasty is currently the most common treatment for displaced femoral neck fractures in the elderly. While bipolar hemiarthroplasty was developed to reduce the risk of acetabular erosion that is associated with traditional unipolar hemiarthroplasty, meta-analyses have reported similar outcomes for bipolar and unipolar hemiarthroplasty devices. The primary objective of this study was to evaluate the risks of aseptic revision and periprosthetic fracture following bipolar versus unipolar hemiarthroplasty in a large integrated health-care system in the United States. Methods: We conducted a retrospective cohort study using data from the hip fracture registry of an integrated health-care system. Patients aged ≥60 years who underwent hemiarthroplasty for hip fracture between 2009 and 2019 were included. The primary outcome measure was aseptic revision, and the secondary outcome measure was revision for periprosthetic fracture. Cause-specific Cox proportional hazards regression was performed, with mortality considered as a competing event. In the multivariable analysis, estimates were adjusted for potential confounders such as age, sex, race/ethnicity, body mass index, American Society of Anesthesiologists classification, femoral fixation, surgeon volume, type of anesthesia, and discharge disposition. Results: The study sample included 13,939 patients who had been treated with hemiarthroplasty by 498 surgeons at 35 hospitals. The mean follow-up time was 3.7 ± 2.9 years. The overall incidence of aseptic revision at 5 years following hemiarthroplasty was 2.8% (386). In the multivariable analysis controlling for potential confounders, bipolar hemiarthroplasty was associated with a lower risk of aseptic revision than unipolar hemiarthroplasty (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.59 to 0.94; p = 0.012). Rates of revision for periprosthetic fracture were similar between the bipolar and unipolar devices (HR, 0.79; 95% CI, 0.58 to 1.10; p = 0.16). Conclusions: In this study of hemiarthroplasty for hip fracture in elderly patients, bipolar designs were associated with a lower risk of aseptic revision than unipolar designs. In contrast to prior research, we did not find any difference in the risk of periprosthetic fracture between the 2 designs. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Sex- and ethnic-specific patterns in the incidence of hip fracture among older US Asian and non-Hispanic White adults.

BACKGROUND: Asian and Pacific Islander (Asian/PI) adults have lower hip fracture incidence than non-Hispanic White (NHW) adults, but data regarding Asian/PI subgroups are limited. We compared hip fracture incidence among older US Asian/PI and NHW populations, including ethnic subgroup differences. METHODS: Using observational data from a California healthcare system, we identified Asian/PI and NHW adults aged ≥50 years (2000-2019) and followed subjects to 2021 for hip fracture determined by principal/primary hospital diagnosis or by secondary hospital diagnosis with hip/femur procedure codes. Age-adjusted hip fracture incidence was calculated with 95% confidence intervals (CIs). Log-Poisson regression was used to determine fracture incidence rate ratios (IRRs, [CI]; NHW or Chinese as reference) adjusting for age and year. RESULTS: Among 215,359 Asian/PI and 776,839 NHW women, hip fracture incidence was 1.34 (1.28-1.40) and 2.97 (2.94-3.01) per 1000 person-years, respectively, with IRR 0.45 (0.43-0.47). Among 188,328 Asian/PI and 697,046 NHW men, hip fracture incidence was 0.62 (0.58-0.67) and 1.81 (1.78-1.84) per 1000 person-years, respectively, with IRR 0.34 (0.32-0.37). For the four largest Asian/PI subgroups, Filipina women (IRR 0.85 [0.75-0.96]) had lower, and Japanese (IRR 1.36 [1.20-1.54]) and South Asian (IRR 1.36 [1.07-1.72]) women had higher hip fracture incidence compared to Chinese women. Hip fracture incidence was only higher among South Asian (IRR 1.61 [1.21-2.14]) compared to Chinese men. CONCLUSION: Hip fracture incidence among US Asian/PI adults was 55% (women) and 66% (men) lower than NHW adults, but incidence varied by Asian/PI subgroup. The heterogeneity among Asian/PI adults highlights the importance of examining fracture risk by ethnic subgroup.

Radial head arthroplasty: a descriptive study of 970 patients in an integrated health care system.

BACKGROUND: Radial head arthroplasty (RHA) is commonly performed for isolated comminuted radial head fractures and in conjunction with traumatic elbow instability. However, there is a paucity of literature directly describing the characteristics and outcomes of patients who undergo RHA in a community-based setting. We describe a cohort of 970 RHA performed in the California regions of a US integrated health care system over a 9-year period. Patient demographics, implant selection, 90-day acute postoperative events, and cumulative reoperation/revision rates are included. METHODS: Patients aged ≥18 years who underwent primary RHA were identified (2009-2017). Patient characteristics and demographics, including age, body mass index, gender, diabetes status, American Society of Anesthesiologists (ASA) classification, primary diagnosis, and concomitant procedures were described. Crude cumulative revision and reoperation probabilities were calculated as 1 minus the Kaplan-Meier estimator, with follow-up time calculated as the time from the index RHA to revision/reoperation date for those with the outcome of interest and time from index RHA to censoring date (eg, date of death, health care termination, study end date [March 31, 2018]) for those without the outcome. Ninety-day postoperative incidence of emergency department (ED) visit, readmission, and mortality was calculated as the number of patients with the event of interest over the number of patients at risk. RESULTS: A total of 970 patients underwent primary unilateral RHA by 205 surgeons during the study period. Annual procedure volume increased from 53 procedures in 2009 to 157 procedures in 2017. More patients were female, without diabetes, and had an ASA classification of 1 or 2. Fracture was the predominant indication for RHA (98.4%) and more than half (54.3%) had concomitant procedures performed. Most implants were press fit (63.2%) over loose fit, and >90% were monopolar. Three-year cumulative revision and reoperation probabilities following RHA were 6.5% (95% confidence interval [CI] = 5.0%-8.5%) and 8.2% (95% CI = 6.5%-10.3%), respectively. Revisions and reoperations tended to occur within the first postoperative year. Of the 970 RHA patients, 83 (8.5%) had a 90-day ED visit, 58 (6.0%) had a 90-day readmission, and 1 (0.1%) died within a 90-day postoperative period. CONCLUSION: This large cohort of RHA patients provides information about the practice of RHA at large and in the community. Surgeons are performing more RHA over time and choosing press fit stems more often. Revisions and reoperations tended to occur early. Readmission and ED visits were low but not negligible, with pain being the most common reason for ED visit.

Total Elbow Arthroplasty: A Descriptive Analysis of 170 Patients From a United States Integrated Health Care System.

PURPOSE: Total elbow arthroplasty (TEA) can be used, with varying degrees of success, for the treatment of rheumatoid arthritis, osteoarthritis, and distal humerus fractures and their sequelae in elderly patients. Some of the largest studies of TEA have included data from more than 20 years ago and may not reflect the current practice of TEA. We sought to describe a modern cohort of patients who underwent TEA in a United States integrated health care system. METHODS: All patients aged 18 years and older who underwent primary unilateral TEA from January 1, 2009, through March 31, 2018, were identified to conduct a descriptive study. The patients' characteristics and demographics, including age, body mass index, sex, diabetes status, American Society of Anesthesiologists classification, and surgical indication, were recorded. The crude cumulative revision probability as well as the 90-day postoperative incidence rate of emergency department visit, readmission, and mortality was calculated. RESULTS: A total of 170 patients met our inclusion criteria. The annual procedure volume nearly doubled, from 11 procedures in 2009 to 21 procedures in 2017. The most common indication for TEA was fracture (40.6%), followed by rheumatoid arthritis (36.5%). At 4-year follow up, the crude cumulative revision probability was 9.8% (95% confidence interval, 5.6%-16.9%). Of the 170 patients who underwent TEA, 43 (25.3%) experienced a 90-day emergency department visit, 24 (14.1%) experienced a 90-day readmission, and 2 (1.2%) died within 90 days postoperatively. CONCLUSIONS: This cohort of patients who underwent TEA using modern implants showed a notable increase in the volume of TEA over the study period, with more TEAs performed for trauma. The incidence of readmission and emergency department visits following TEA were high in this study. Further studies are needed to better define the current practice of TEA in the community at large. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Vascular anatomy relevant to distal biceps tendon repair.

BACKGROUND: Avoiding bleeding and vascular complications in open repair of distal biceps tendon rupture requires knowledge of the local vascular anatomy. This study examined the vascular anatomy relevant to distal biceps tendon repair. METHODS: The antecubital regions of 17 cadaveric upper extremities were dissected using ×2.5 loupe magnification to identify the brachial artery, the radial artery and its recurrent branches, and venous branches crossing the distal biceps tendon. With the elbow in full extension and supination, the position of each vascular structure was measured relative to the most proximal aspect of the bicipital tuberosity. RESULTS: The most common pattern (13 of 17 specimens) was a single radial recurrent artery (RRA) crossing volar to the tendon at a mean of 4 mm proximal to the tuberosity and positioned 15.4 mm volar to the tuberosity. The RRA bifurcated 2 to 9 mm from its origin in 6 arms and demonstrated a single bifurcation. In 8 of 17 specimens, an additional recurrent branch off the brachial artery traveled dorsal to the intact biceps tendon 16 mm proximal to the RRA. Two arms demonstrated a high brachial artery bifurcation. The crossing veins were venae comitantes of the RRAs and radial and ulnar arteries. They connected to the superficial veins by way of a perforating branch. Most often, 3 transverse veins positioned on average 0.2 mm proximal and 16 mm volar to the tuberosity were seen. CONCLUSIONS: The vascular anatomy encountered during distal biceps repair is variable, and RRAs occasionally travel dorsal to the biceps tendon. Most often, a single RRA on average 4 mm proximal to the tuberosity will branch once.