Early morbidity after aseptic revision hip arthroplasty in Denmark

Patient-Related Predictors of Treatment Failure after Two-Stage Total Hip Arthroplasty Revision for Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis

INTRODUCTION

Periprosthetic joint infection (PJI) treatment has high failure rates even after two-stage revision. Risk factors for treatment failure after staged revision for PJI are not well defined, nor is it well established how they correlate with the risks of developing an index PJI. Identifying modifiable risk factors may allow preoperative optimization, while identifying non-modifiable risk factors can influence surgical options or advise against further surgery. We performed a systematic review and meta-analysis to better define predictors of treatment failure in two-stage revision for PJI.

METHODS

The Pubmed, Embase, and Scopus databases were searched from their inception in December 1976 to April 15, 2023. Studies comparing patient-related variables between patients successfully treated who had two-staged revision total hip arthroplasty and patients with persistent infections were included. Studies were screened, and two independent reviewers extracted data, while a third resolved discrepancies. Meta-analysis was performed on these data. There were 10,052 unique studies screened, and 21 studies met the inclusion criteria for data extraction.

RESULTS

There was good-quality evidence that obesity, liver cirrhosis, and previous failed revisions for PJI are non-modifiable risk factors, while intravenous drug use and smoking are modifiable risk factors for treatment failure after two-stage revision for hip PJI. Reoperation between revision stages was also significantly associated with an increased risk of treatment failure. Interestingly, other risk factors for an index PJI including male gender, American Society of Anaesthesiology score, diabetes mellitus and inflammatory arthropathy did not predict treatment failure. Evidence on Charlson Comorbidity Index was limited.

DISCUSSION

Patients with a smoking history, obesity, intravenous drug use, previous failed revision for PJI, reoperation between stages and LC are more likely to experience TF after two-stage revision THA for PJI. Modifiable risk factors include smoking and IVDU and these patients should be referred to services for cessation as early as possible before two-stage revision THA.

Registry Data Show Complication Rates and Cost in Revision Hip Arthroplasty

INTRODUCTION

Revision THA (rTHA) places a burden on patients, surgeons, and health care systems because outcomes and costs are less predictable than primary THA. The purposes of this study were to define indications and treatments for rTHA, quantify risk for readmissions and evaluate the economic impacts of rTHA in a hospital system.

METHODS

The arthroplasty database of a hospital system was queried to generate a retrospective cohort of 793 rTHA procedures, performed on 518 patients, from 2017 to 2019 at 27 hospitals. Surgeons performed chart reviews to classify indication and revision procedure. Demographics, lengths of stay (LOS), discharge dispositions, and readmission data were collected. Analyses of direct costs were performed and categorized by revision type.

RESULTS

46.3% of patients presented for infection. Patients presenting for infection were 5.6 times more likely to have repeat rTHA than aseptic patients. Septic cases (4.3 days) had longer LOS than aseptic ones (2.4) (P < 0.0001). 31% of patients discharged to a skilled nursing facility (SNF). Direct costs were greatest for a two-stage exchange ($37,642), and lowest for liner revision ($8,979). Septic revisions ($17,696) cost more than aseptic revisions ($11,204) (P< 0.0001). The 90-day readmission rate was 21.8%. Septic revisions had more readmissions (13.5%) than aseptic revisions (8.3%).

CONCLUSIONS

Hip revisions, especially for infection, have an increased risk profile and create a major economic impact on hospital systems. Surgeons may use these data to counsel patients on risks of rTHA and advocate for improved reimbursement for the care of revision patients.

Patient safety in distal femoral resection knee arthroplasty for non-tumor indications: a single-center consecutive cohort study of 45 patients

BACKGROUND

Distal femoral resection knee arthroplasty may be a viable option for several indications other than bone tumors. Resection knee arthroplasty appears to be becoming more common, but patients requiring this type of surgery are often elderly and with high comorbidity. The aim of this study was to report in-hospital complications, readmissions, reoperations, and mortality after distal femoral resection knee arthroplasty for non-tumor indications.

METHODS

We retrospectively identified a consecutive cohort of 45 knees (45 patients) treated with distal femoral resection knee arthroplasty in a single institution between 2012 and 2021. Indications for surgery were failure of osteosynthesis (8), primary fracture treatment (2), periprosthetic fracture (22), and revision arthroplasty with severe bone loss (13). A major reoperation was defined as a major component exchange procedure or amputation. Mean follow-up was 3.9 years.

RESULTS

The mean age was 71.3 years (SD 12.3), and 64.4% were female; 8.9% were ASA I, 40% ASA II, and 51% ASA III. Median length of stay was 7 days (range 3-19) with no major in-hospital complications, but 55.6% (n = 25) required blood transfusion. The 90-day readmission rate was 17.8% (n = 8), of which 50% was prosthesis-related. Four patients (8.9%) underwent major reoperation due to infection (n = 2), mechanical failure (n = 1), or periprosthetic fracture (n = 1). The mortality rate was 0% ≤ 90 days and 2.2% ≤1 year.

CONCLUSIONS

Distal femoral resection knee arthroplasty in this fragile patient population appears to be a viable and safe option considering that it is a limp salvage procedure most cases.

Re-revision total hip arthroplasty: Epidemiology and factors associated with outcomes

INTRODUCTION

The epidemiology of re-revision total hip arthroplasty (THA) is not yet well-understood. We aim to investigate the epidemiology and risk-factors that are associated with re-revision THA.

METHODS

288 revision THA were analyzed between 1/2012 and 12/2013. Patients who underwent two or greater revision THA were included. Hips with first-revision due to periprosthetic joint infection (PJI) were excluded. Failure was defined as reoperation.

RESULTS

51 re-revision patients were available. Mean age was 59.6 (±14.2 years), 32 (67%) females, average BMI of 28.8 (±5.4), and median ASA 2 (23; 55%). The most common re-revision indications were acetabular component loosening (15; 29%), PJI (13; 25%) and instability (9; 18%). The most common indications for first revision in the re-revision population were acetabular component loosening (11; 27%), polyethylene wear (8; 19%) and instability (8; 19%). There was an increased risk of re-revision failure if the re-revision involved exchanging only the head and polyethylene liner (RR = 1.792; p = 0.017), instability was the first-revision indication (RR = 3.000; p < 0.001), and instability was the re-revision indication (RR = 1.867; p = 0.038). If isolated femoral component revision was indicated during the re-revision, there was a decreased risk of failure (RR = 0.268, p = 0.046). 1-year re-revision survival was 54% (23/43).

DISCUSSION

Acetabular component loosening, instability, and PJI were the most common indications for re-revision. Revision due to instability is a recurrent problem that leads to re-revision failure. There was a higher infection rate in the re-revision population compared to published revision PJI. A better understanding of the indications and patient factors that are associated with re-revision failures can help align surgeon and patient expectations in this challenging population.

Low Hospital Volume Increases Revision Rate and Mortality Following Revision Total Hip Arthroplasty: An Analysis of 17,773 Cases

BACKGROUND

With the number of primary total hip arthroplasty (THA), the amount of revision THA (R-THA) increases. R-THA is a complex procedure requiring special instruments, implants, and surgical skills. Therefore it is likely that hospitals performing a higher number of R-THAs have more experience with this type of surgery and therefore fewer complications. The purpose of this study was to evaluate the relationship between hospital volume and risk of postoperative complications following R-THA.

METHODS

Using nationwide healthcare insurance data for inpatient hospital treatment, 17,773 aseptic R-THAs in 16,376 patients treated between January 2014 and December 2016 were included. Outcomes were 90-day mortality, 1-year revision procedures, and in-house adverse events. The effect of hospital volume on outcome was analyzed by means of multivariate logistic regression. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Hospital volume had a significant effect on 90-day mortality (≤12 cases per year: OR 2.13, CI 1.53-2.96; 13-24: OR 1.79, CI 1.29-2.50; 25-52: OR 1.53, CI 1.11-2.10; ≥53: reference) and 1-year revision procedures (≤12: OR 1.26, CI 1.09-1.47; 13-24: OR 1.18, CI 1.02-1.37; 25-52: OR 1.03, CI 0.90-1.19; ≥53: reference). There was no significant effect on risk-adjusted major in-house adverse events.

CONCLUSION

We found evidence of higher risk for revision surgery and mortality in hospitals with fewer than 25 and 53 R-THA per year, respectively. To improve patient care, complex elective procedures like R-THA which require experience and a specific logistic background should be performed in specialized centers.

Total Hip Arthroplasty Performed for Coxarthrosis Preserves Long-Term Physical Function: A 40-Year Experience

BACKGROUND

Measures of long-term success of total hip arthroplasty (THA) over the past 50 years have focused primarily on implant survival, with less evidence on long-term functional outcomes.

QUESTIONS/PURPOSES

We aimed to study 20-to-40-year functional outcomes after primary THA. We investigated the extent to which (1) functional outcomes after THA are maintained long term; (2) patient characteristics such as age, hip disease diagnosis, and comorbidities affect recovery of function and survivorship after THA; and (3) patients' overall function after THA is affected by the need for revision, the aging process, and associated comorbidities.

METHODS

We retrospectively reviewed outcomes of the senior author's patients between 1968 and 1993. Of 1207 patients, we identified 167 patients (99 female, 68 male; 276 primary THAs) who were at least 65 years old at follow-up and had at least 20 years of follow-up. Mean age at surgery was 55 years; mean follow-up time was 27 years. Bilateral THAs were performed in 109 patients (65%), and revisions in 81 patients (48.5%). Clinical outcomes including pain level, walking ability, range of motion, and overall function were determined by the Hospital for Special Surgery (HSS) hip scoring system. Contralateral and revision surgery, as well as patient age, sex, and body mass index, were included as covariates. To account for unequally spaced follow-up time points and competing causes of functional decline (e.g., age, contralateral hip disease, and need for revision THA), a latent class mixed model approach was used to identify unobserved classes of patients who had similar outcomes. Linear, quadratic, and piecewise-polynomial growth models were considered for class identification. The best fitting model was determined based on Bayesian information criterion.

RESULTS

A four-class model of this patient population was identified: (1) the Elderly Class, who had a mean age of 62 years at the time of primary THA; (2) the Bilateral Class, who underwent simultaneous or staged bilateral THA; (3) the Revision Class, who required at least one revision; and (4) the Youngest Class, who had a mean age of 49 years. After an initial period of improvement in all groups, the functional trajectory diverged according to classifications. Age was the strongest determinant of long-term outcome, with HSS hip scores in the Elderly Class declining after about 20 years. The Youngest Class maintained good-to-excellent hip function for over 30 years. Revision THA and contralateral THA accounted for a temporary decline in function, after which overall good function was regained for the long term.

CONCLUSIONS

All classes in the study population enjoyed good-to-excellent outcomes after THA for about 20 years. Thereafter, functional decline was attributed more to aging than to the need for revision. One or more revision THA did not negatively influence long-term clinical outcomes, suggesting that, even for younger patients, symptoms, rather than the avoidance of possible revision, should be the primary determining factor when indicating THA.

Early death following revision total hip arthroplasty

INTRODUCTION

The frequency of primary total hip arthroplasty procedures is increasing, with a subsequent rise in revision procedures. This study aims to describe timing and surgical mortality associated with revision total hip arthroplasty (THA) compared to those on the waiting list.

METHODS

All patients from a single institution who underwent revision total hip arthroplasty or were added to the waiting list for the same procedure between 2003 and 2013 were recorded. Mortality rates were calculated at 30 and 90 days following surgery or addition to the waiting list.

RESULTS

561 patients were available for the survivorship analysis in the surgical group. Following exclusion, 901 and 484 patients were available for the 30 and the 90-day analysis in the revision THA waiting list group. 30- and 90-day mortality rates were significantly greater for the revision THA group compared to the waiting list group (excess surgical mortality at 30 days = 0.357%, p = 0.037; odds ratio of 5.22, excess surgical mortality at 90 days = 0.863%, p = 0.045).

CONCLUSIONS

Revision total hip arthroplasty is associated with a significant excess surgical mortality rate until 90 days post-operation when compared to the waiting list population. We would encourage other authors with access to larger samples to use our method to quantify excess mortality after both primary and revision arthroplasty procedures.

Cementless One-Stage Revision in Chronic Periprosthetic Hip Joint Infection. Ninety-One Percent Infection Free Survival in 56 Patients at Minimum 2-Year Follow-Up

BACKGROUND

Cementless 1-stage revision in chronic periprosthetic hip joint infections is limited evaluated. The purpose of this study was to evaluate a specific treatment protocol in this patient group.

METHODS

The study was performed as a multicenter, proof-of-concept, observational study with prospective data collection. Patients were treated with a cementless 1-stage revision according to the CORIHA protocol between 2009 and 2014. Fifty-six patients, McPherson type III-A/B-1/2, were enrolled with a mean follow-up time from the CORIHA procedure of 4 years (minimum of 2 years). The primary outcome was re-revision performed due to infection and was evaluated by competing risk analysis, with death and aseptic revision as competing events. All-cause mortality was evaluated by Kaplan-Meier survival analysis. Oxford Hip Score (OHS) was used as disease-specific patient-reported outcome measure.

RESULTS

The cumulative incidence of re-revision due to infection was 8.9% (confidence interval [CI] 3.2%-18.1%). The 1-year and 5-year survival incidence was 96% (CI 86%-99%) and 89% (CI 75%-95%). OHS at baseline was 19.9 (CI 17.3-22.6) and at 24-month follow-up 35.1 (CI 31.7-38.5). The mean change in OHS from baseline to 24-month follow-up was 11.8 points (CI 7.3; 16.3). Three patients had aseptic revision performed: two suffered periprosthetic fractures and one had stem subsidence. Failure analysis of the 5 reinfections did not detect a clear pattern as to the cause of failure.

CONCLUSION

We found that cementless 1-stage revision in chronic periprosthetic hip joint infections has low reinfection rates in selected patients and may be applicable as a first-line treatment.

Enhanced recovery principles applied to revision hip and knee arthroplasty reduces length of stay and blood transfusion

INTRODUCTION

This is the first study reporting the application of Enhanced Recovery Principles (ERP) to revision arthroplasty.

METHOD

Retrospective series of 132 revision hip and knee replacements treated with ERP.

RESULTS

Infiltration was associated with reduced LOS in knees (6 vs 8.5 days), lower PCA usage and incidence of transfusion in knees (2 vs 3 days) and hips (1 vs 6 days). Revisions for infection had a longer LOS (5.4 vs 11.5 days p = 0.001), a greater use of PCA and a higher incidence of transfusion (5 vs 0) in both knees and hips.

DISCUSSION

The application of ERPs to revision arthroplasty is safe. Infiltration appears to be an important factor in improving outcome measures.

Peri-prosthetic tissue cells show osteogenic capacity to differentiate into the osteoblastic lineage

During the process of aseptic loosening of prostheses, particulate wear debris induces a continuous inflammatory-like response resulting in the formation of a layer of fibrous peri-prosthetic tissue at the bone-prosthesis interface. The current treatment for loosening is revision surgery which is associated with a high-morbidity rate, especially in old patients. Therefore, less invasive alternatives are necessary. One approach could be to re-establish osseointegration of the prosthesis by inducing osteoblast differentiation in the peri-prosthetic tissue. Therefore, the aim of this study was to investigate the capacity of peri-prosthetic tissue cells to differentiate into the osteoblast lineage. Cells isolated from peri-prosthetic tissue samples (n = 22)-obtained during revision surgeries-were cultured under normal and several osteogenic culture conditions. Osteogenic differentiation was assessed by measurement of Alkaline Phosphatse (ALP), mineralization of the matrix and expression of several osteogenic genes. Cells cultured in osteogenic medium showed a significant increase in ALP staining (p = 0.024), mineralization of the matrix (p < 0.001) and ALP gene expression (p = 0.014) compared to normal culture medium. Addition of bone morphogenetic proteins (BMPs), a specific GSK3β inhibitor (GIN) or a combination of BMP and GIN to osteogenic medium could not increase ALP staining, mineralization, and ALP gene expression. In one donor, addition of GIN was required to induce mineralization of the matrix. Overall, we observed a high-inter-donor variability in response to osteogenic stimuli. In conclusion, peri-prosthetic tissue cells, cultured under osteogenic conditions, can produce alkaline phosphatase and mineralized matrix, and therefore show characteristics of differentiation into the osteoblastic lineage. © 2016 The Authors. Journal of Orthopaedic Research published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 35:1732-1742, 2017.

Time course and reasons for 90-day mortality in fast-track hip and knee arthroplasty

BACKGROUND

Post-operative mortality is an important adverse outcome, including in total hip (THA) and knee arthroplasty (TKA). However, whether mortality is due to anaesthetic/surgical complications, surgically induced organ dysfunction or unrelated to surgery is rarely considered.

METHODS

Prospective observational study in 13,775 consecutive THA/TKAs with similar fast-track protocols and a median length of stay of 2 days. Complete 90-days follow-up through national registries, followed by review of medical records and death certificates. Relation between mortality and surgically induced organ dysfunction were classified as certain, probable, possible or unlikely.

RESULTS

Of a total of 44 deaths (0.3%), 28 (0.2%) were found to have certain or probably relation with surgery and were considered as surgery-related. Surgery-related deaths were more common after THA than TKA (0.3% vs. 0.1% P = 0.044), occurred after median 14 days and 19 of 28 were between day 0-30. Of the remaining 16 deaths (0.1%), nine were found to be possible and seven to be unlikely related to surgery, and occurred a median of 42 and 61 days after surgery. The most common initial organ dysfunction for surgery-related deaths was pulmonary (6/28) and gastrointestinal (6/28), while the most common reported cause of death were pulmonary (9/28) and cardiac events (6/28). In five of the seven unlikely related deaths mortality was attributed to underlying cancer.

CONCLUSION

Ninety-days mortality was 0.3% in THA and TKA, but only 28 of 44 deaths (64%) were found to be surgery-related. Reporting total mortality rate or cause of death without considerations on surgery induced organ dysfunction, may be insufficient for future aims to reduce post-operative mortality.

Perioperative Complications and Length of Stay After Revision Total Hip and Knee Arthroplasties: An Analysis of the NSQIP Database

Goals of this study were (1) to determine the 30-day complications after aseptic revision hip arthroplasty (RHA) and aseptic revision knee arthroplasty (RKA) and (2) to identify patient-related risk factors predicting major complications and prolonged hospital stay beyond 7 days. The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients with RHA (n=2643) or RKA (n=2425) from 2011 to 2012. The 30-day mortality rates for RHA and RKA were 1.0% and 0.1% (P<0.001) and the overall complication rates were 7.4% and 4.7% (P<0.001) for RHA and RKA, respectively. Multivariable analysis showed that preoperative anemia is the most important modifiable independent predictor for both major complications and prolonged hospital stay after RHA and RKA.