Revision Total Hip Arthroplasty in Octogenarians Compared with Septuagenarians: Is There a Real Difference?

Low Incidence of Reoperation of Modular Fluted Tapered Stems in Aseptic Revision Total Hip Arthroplasty in Patients 75 Years and Older

BACKGROUND

Modular fluted tapered (MFT) stems have become popular in revision total hip arthroplasty (THA); therefore, it is imperative to understand the clinical outcomes of these stems, particularly in elderly patients, a population that has seldom been studied. This study aimed to report the cumulative incidence of reoperation among elderly patients who underwent aseptic revision THA with MFT stems.

METHODS

A prospective cohort of 98 patients 75 years and older who underwent aseptic revision THA with MFT stems between June 1, 2015 and December 31, 2020 was analyzed. Medical record review identified patients who underwent reoperation of the hip, which was defined as any cause requiring the operating room. A cumulative incidence plot with death as a competing event was used to visualize reoperation occurrence. The median follow-up was 4.5 years (range, three days to nine years).

RESULTS

The cumulative incidence of reoperation was 6.1% (95% CI [confidence interval]: 2.5 to 12) at two years. Causes of reoperation were periprosthetic fracture (3), dislocation (1), periprosthetic joint infection (PJI) (1), and symptomatic hardware (1). Only the PJI case required re-revision of the MFT stem. There were no cases of aseptic loosening. Patients who underwent reoperation were younger (77 versus 81 years, P = 0.037), and more underwent revision THA through a direct anterior approach (33.3 versus 2.8%, P = 0.027).

CONCLUSION

In patients 75 years and older undergoing aseptic revision THA with MFT stems, the cumulative incidence of reoperation was 6.1% at two years. The MFT stem remains an acceptable option in older patients undergoing aseptic revision THA.

Aseptic Revision Total Knee Arthroplasty in Octogenarians: A Matched Cohort Comparison of Early Clinical Outcomes

BACKGROUND

With increasing volume and life expectancy of patients undergoing total knee arthroplasty (TKA), the incidence of octogenarian patients requiring revision TKA (rTKA) will similarly rise. There remains limited evidence regarding the safety of revision procedures in octogenarians who may carry an increased risk of medical and surgical complications. Therefore, the purpose of our analysis was to evaluate early clinical outcomes following rTKA in patients aged ≥ 80 years compared with younger matched controls.

METHODS

Patients who underwent aseptic all-component rTKA between 2010 and 2020 at a multiple-surgeon, single-site institution were reviewed. Patients aged ≥ 80 years were matched to cohorts of patients aged ≥ 40 to 59 years and ≥ 60 to 79 years undergoing rTKA based on sex, American Society of Anesthesiologists score, and body mass index. Multivariate regression analysis of 90-day postoperative medical and surgical complications, controlling for comorbidity burden, smoking status, and revision etiology, was conducted. A total of 210 patients (n = 70 per cohort) were evaluated.

RESULTS

There were no differences between octogenarians and younger patients for medical (odds ratio [OR]: 0.32; 95% confidence interval [CI]: 0.053 to 1.91; P = 0.2), surgical (OR: 1.61, 95% CI: 0.42 to 6.19; P = 0.5), and overall complications (OR: 0.52, 95% CI: 0.17 to 1.60; P = 0.3) at 90 days. Octogenarians had a statistically lower risk of reoperation relative to younger controls (OR: 0.22, 95% CI: 0.054 to 0.85; P = 0.03).

CONCLUSIONS

Octogenarians undergoing rTKA had comparable early postoperative clinical outcomes compared to younger matched controls. These findings suggest that appropriately indicated octogenarians requiring all-component rTKA may safely undergo these procedures. Adult reconstruction surgeons must consider both age and comorbidity burden when counseling these patients regarding the risks associated with revision surgery.

Predicting Early Hospital Discharge Following Revision Total Hip Arthroplasty: An Analysis of a Large National Database Using Machine Learning

BACKGROUND

Revision total hip arthroplasty (rTHA) was recently removed from the Medicare inpatient-only list. However, appropriate candidate selection for outpatient rTHA remains paramount. The purpose of this study was to evaluate the utility of a large national database using machine learning (ML) and traditional multivariable logistic regression (MLR) models in predicting early hospital discharge (EHD) (< 24 hours) following rTHA. Furthermore, this study aimed to use the trained ML models, cross-referenced with traditional MLR, to determine key perioperative variables predictive of EHD following rTHA.

METHODS

Data were obtained from a large national database from 2021. Patients who had unilateral rTHA procedures were included. Demographic, preoperative, and operative variables were analyzed as inputs for the models. An ML regression model and various ML techniques were used to predict EHD and were compared using the area under the curve, calibration, Brier score, and decision curve analysis. Feature importance was identified from the overall best-performing model. Of the 3,097 patients in this study, 866 (27.96%) underwent EHD.

RESULTS

The random forest model performed the best overall and identified aseptic surgical indication, operative time < three hours, absence of anemia (hematocrit < 40% in men and < 35% in women), neuraxial anesthesia type, White race, men, independent functional status, body mass index > 20, age < 75 years, and the presence of home support as factors predictive of EHD. Each of these variables was also significant in the MLR model.

CONCLUSIONS

Each ML model and MLR displayed good performance and identified clinically important variables for determining candidates for EHD following rTHA. Machine learning (ML) techniques such as random forest may allow clinicians to accurately risk stratify their patients preoperatively to optimize resources and improve patient outcomes.

The CCJR® Charles A. Engh, Sr, MD. Excellence in Hip Research Award: The Evolution of Revision Hip Arthroplasty and Impact on the Trainee's Experience

BACKGROUND

Advances in total hip arthroplasty (THA) have resulted in evolving revision indications and intraoperative techniques, which can influence the exposure of trainees to complex cases. We report 3 decades of revision experience from a tertiary referral center that trains fellows, comparing the reasons for revision and the complexity of revisions over time.

METHODS

We retrospectively reviewed all revision THAs performed at our institution from 1990 to 2022. Revision diagnoses, components revised, types of revision implants used, and exposure techniques were collected. A "complex" revision was defined as a case that involved an extended trochanteric osteotomy, triflange and cup-cage construct, or acetabular augment.

RESULTS

A total of 3,556 THA revisions were identified (108 revisions/year). Aseptic loosening was the most common indication in 1990 to 1999 (45 per year), but decreased to 28.3/year in 2010 to 2019. From 1990 to 1999 and 2010 to 2019, fracture increased from 3.1 to 7.3 per year, infection from 2.9/year to 16.9/year, and metallosis from 0.1 to 13.2 per year. Both component revision were common from 1990 to 1994 (42.6 per year), while polyethylene exchange was most common in 2010 to 2019 (43.3 per year). A decrease was observed in "complex" cases over time: 14.8 extended trochanteric osteotomies/year in 2000 to 2004 compared to 5.4 per year in 2018 to 2022, 4.5 triflange and cup-cage constructs/year in 2004 to 2007 compared to 0.8 per year in 2018 to 2022, and 4 acetabular augments per year in 2009 to 2012 compared to 1 per year in 2018 to 2022.

CONCLUSIONS

Indications for revision have changed over the decades, while the number of "complex" revisions has gradually decreased, presumably due to advances in implants and materials. If this trend extends to other training institutions, the next generation of arthroplasty surgeons will have less exposure to complex revisions during their training.