Aims. The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate?. Methods. PHFs occurring between 1 January 2009 and 31 December 2019 were identified from the Medicare physician service records. Incidence rates were determined, mortality rates were calculated, and semiparametric Cox regression was applied, incorporating 23 demographic, clinical, and socioeconomic covariates, to compare the mortality risk between treatments. Results. From 2009 to 2019, the incidence decreased by 11.85% from 300.4 cases/100,000 enrollees to 266.3 cases/100,000 enrollees, although this was not statistically significant (z = -1.47, p = 0.142). In comparison to matched Medicare patients without a PHF, but of the same five-year age group and sex, a mean survival difference of -17.3% was observed. The one-year mortality rate was higher after nonoperative treatment with 16.4% compared to surgical treatment with 9.3% (hazard ratio (HR) = 1.29, 95% confidence interval (CI) 1.23 to 1.36; p < 0.001) and to shoulder arthroplasty with 7.4% (HR = 1.45, 95% CI 1.33 to 1.58; p < 0.001). Statistically significant mortality risk factors after operative treatment included age older than 75 years, male sex,
The primary aim was to assess whether preoperative health-related quality of life (HRQoL) was associated with postoperative mortality following total hip arthroplasty (THA) and knee arthroplasty (KA). Secondary aims were to assess whether patient demographics/comorbidities and/or joint-specific function were associated with postoperative mortality. Patients undergoing THA (n = 717) and KA (n = 742) during a one-year period were identified retrospectively from an arthroplasty register. Patient demographics, comorbidities, Oxford score, and EuroQol five-dimension (EQ-5D) were recorded preoperatively. Patients were followed up for a minimum of seven years and their mortality status was obtained. Cox regression analysis was used to adjust for confounding.Aims
Methods
The burden of hospital length of stay (LOS) and readmissions for total hip arthroplasty (THA) patients has resulted in great scrutiny. The purpose of this study was to determine our patients' LOS and hospital readmissions over the past 7 years. The second purpose was to determine what comorbidities affected the LOS and readmissions of 1440 THA patients. 1440 THA patients were retrospectively reviewed. The group included 622 males, 818 females. The average age of the cohort was 60 years (12 to 94 years). Ninety-day hospital readmissions were measured for the patients. Fisher's exact test, independent Sample t-test and Spearman correlation coefficients were used to determine associations of patient characteristics and comorbidities with readmission status and LOS with comorbidity status. The LOS decreased over the time of the study (p=0.02), however; readmissions remained constant at approximately 6% (p=0.73). The mean LOS for patients not readmitted was significantly shorter than for those readmitted (3.2 vs. 4.4 days; p=0.0003). Comorbidities associated with a longer hospital stay included diabetes (p=0.0052), hypertension (p=0.04), coronary artery disease (p=0.0034), congestive heart failure (p=0.0012), peripheral vascular disease (p=0.015),
Background. Fungal infection at an arthroplasty site is rare and poses a therapeutic challenge. To the best of our knowledge, no reports have been published thus far on the success rate of prosthesis reimplantation after fungal prosthetic joint infections. Questions/purposes. We asked: (1) What is the success rate in terms of infection eradication using a two-stage exchange arthroplasty in patients with hip or knee fungal periprosthetic joint infections, particularly focusing on Candida infections? (2) What patient-, infection-, and treatment-related variables are associated with the success or failure of treatment?. Methods. From January 2000 to December 2010, 16 patients with hip or knee candidal periprosthetic joint infections were treated with two-stage exchange arthroplasty at our institute. Treatment success was defined as a well-functioning joint without relapse of candidal infection after prosthesis reimplantation, while treatment failure was defined as uncontrolled or a relapse of candidal infection or mortality. Variables, including age, sex, comorbidities, microbiology, antimicrobial agents used, and operative methods, were analyzed. Minimum followup was 28 months (mean, 41 months; range, 28–90 months). Results. At latest followup, the treatment failed to eradicate the infection in eight of the 16 patients, and there were four deaths related to fungemia. Four patients required permanent resection arthroplasty owing to uncontrolled or recurrent candidal infections. All eight patients (50% successful rate) who had their infections eradicated and successful prosthesis reimplantation had prolonged treatment with oral fluconazole before (mean, 8 months) and after (mean, 2.2 months) prosthesis reimplantation. The antifungal therapy correlated with successful treatment. Renal insufficiency, hypoalbuminemia, anemia, and
Aims. The EuroQol five-dimension (EQ-5D) questionnaire is a widely used multiattribute general health questionnaire where an EQ-5D < 0 defines a state ‘worse than death’ (WTD). The aim of this study was to determine the proportion of patients awaiting total hip arthroplasty (THA) or total knee arthroplasty (TKA) in a health state WTD and to identify associations with this state. Secondary aims were to examine the effect of WTD status on one-year outcomes. Patients and Methods. A cross-sectional analysis of 2073 patients undergoing 2073 THAs (mean age 67.4 years (. sd. 11.6; 14 to 95); mean body mass index (BMI) 28.5 kg/m. 2. (. sd. 5.7; 15 to 72); 1253 female (60%)) and 2168 patients undergoing 2168 TKAs (mean age 69.3 years (. sd. 9.6; 22 to 91); BMI 30.8 kg/m. 2. (. sd. 5.8; 13 to 57); 1244 female (57%)) were recorded. Univariate analysis was used to identify variables associated with an EQ-5D score < 0: age, BMI, sex, deprivation quintile, comorbidities, and joint-specific function measured using the Oxford Hip Score (OHS) or Oxford Knee Score (OKS). Multivariate logistic regression was performed. EQ-5D and OHS/OKS were repeated one year following surgery in 1555 THAs and 1700 TKAs. Results. Preoperatively, 391 THA patients (19%) and 263 TKA patients (12%) were WTD. Multivariate analysis identified preoperative OHS, deprivation, and
Aim. Haematogenous prosthetic joint infections account for 20-35% of total prosthetic infections. Debridement, antibiotics and implant retention (DAIR) is a well-accepted treatment for these infections and probably the most desired by surgeons, since it tries to maintain a functional and stable implant. However, the risk of DAIR failure is not negligible and some risk factors have been described, and also, different scores, such as CRIME80. Nonetheless, less is known about the impact of positive blood cultures may have on DAIR treatment. The aim of our study is to analyze whether the presence of a positive culture is a risk factor for DAIR failure. Method. A retrospective cohort study of 50 late acute haematogenous TKA infections was performed from 2015 to 2023. DAIR failure was defined as the need of a subsequent intervention either a new DAIR or a revision surgery. So, patients were divided into two groups depending on the surgical outcome: successful (SG) vs failure (FG). Demographic variables including age, gender, affected side and body mass index were collected. Patient's comorbidities were also collected including
Aim. To investigate self-reported quality of life (QoL) in patients with osteomyelitis referred to a specialist centre in the UK and investigate the relationship between QoL and BACH classification. Method. All patients newly referred to a specialist bone infection clinic at a single tertiary centre within the UK between January 2019 and February 2020 were prospectively included. Diagnosis of osteomyelitis was made according to the presence of clinical and radiological criteria for ≥6 months. An EQ-5D-5L questionnaire and visual analogue score (VAS) were completed during the initial clinic appointment. Long-bone osteomyelitis was classified by the attending orthopaedic surgeon using the BACH classification system as either uncomplicated, complex or with limited options available.1 Patients managed non-operatively were subclassified into those who were (i) unfit to receive an operation or (ii) fit and well with stable disease. EQ-5D index scores were compared to a published UK value set of 41 chronic health conditions within the UK.2. Results. 201 patients were referred during the study period, with 159 (79.1%) patients diagnosed with long-bone osteomyelitis and 16 (8.0%) with osteomyelitis of the pelvic bones. Patients with pelvic osteomyelitis reported lower EQ-5D index scores compared to long-bone osteomyelitis (EQ-5D: 0.097 vs. 0.435, p<0.001) but similar VAS (60.2 vs. 54.6, p=0.37). Long-bone and pelvic osteomyelitis gave the 40th and 41st lowest EQ-5D scores respectively when compared to 41 other chronic health conditions including stroke,
Elderly patients undergoing surgery for a hip fracture are at risk of thromboembolic events (TEV). The risk of TEV is now rare due to thromboprophylaxis. However, hip fracture treatment has evolved over the last decade. The risk of TEV may have been modified. The objective of this study was to determine the risk of symptomatic TEV following surgery for a hip fracture, in an elderly population. Retrospective cohort study of all patients > 65 years old undergoing surgery for a femoral neck or intertrochanteric hip fracture in two academic centers, between January 1st 2008 and January 1st 2019. The follow-up was fixed at 3 months. The cumulated risk of thromboembolic events was calculated using the Kaplan-Meier estimator and a predictive logistic regression model was used to determine risk factors. 3265 patients were eligible for analysis. The mean age was 83.3 ±8.1 years old and 75.6% of patients were female. The mortality was 7.55% (N=112) at 3 months. 98.53% of this cohort received thromboprophylaxis. The cumulated risk for a thromboembolic event was 3.55% at 1 month and 6.41% at 3 months (N=99). There were 9 fatal pulmonary embolisms. 89.19% thromboembolic events occurred within 20 days following surgery.
Introduction. This study assesses self-reported quality of life (QoL) in patients with osteomyelitis referred to a specialist centre in the UK. Materials and Methods. All patients newly referred to a specialist tertiary bone infection clinic within the UK between January 2019 and February 2020 were prospectively included. Diagnosis of osteomyelitis was made according to the presence of clinical and radiological criteria for ≥6 months. An EQ-5D-5L questionnaire and visual analogue score (VAS) were completed during the initial clinic appointment. Long-bone osteomyelitis was classified by the attending orthopaedic surgeon using the BACH classification system as either uncomplicated, complex or with limited options available. Patients managed non-operatively were subclassified into those who were (i) unfit to receive an operation or (ii) fit and well with stable disease. EQ-5D index scores were compared to a published UK value-set of 41 chronic health conditions within the UK. Results. 201 new patients were referred during the study period. 159 (79.1%) met the criteria for long-bone osteomyelitis and 16 (8.0%) for osteomyelitis of the pelvic bones. Patients with pelvic osteomyelitis reported lower EQ-5D index scores compared to long-bone osteomyelitis (EQ-5D:0.097 vs. 0.435, p<0.001) but similar VAS (60.2 vs. 54.6, p=0.37). Long-bone and pelvic osteomyelitis gave the lowest EQ-5D scores respectively when compared to 41 other chronic health conditions including stroke,
Introduction. Social determinants of health (SDOH) may contribute markedly to the total cost of care (COC) for patients undergoing elective total knee arthroplasty (TKA). This study investigated the association between demographics, health status, and SDOH on lengths of stay (LOS) and 30-day COC. Methods. Patients who underwent TKA between January 2018 and December 2019 were identified. Those who had complete SDOH data were utilized, leaving 234 patients. Data elements were drawn from the Chesapeake Regional Information System, the Center for Disease Control social vulnerability index (SVI), the Food Access Research Atlas (FARA). The SVI identifies areas vulnerable to catastrophic events, with 4 themed scores including: (1) socioeconomic status; (2) household composition and disability; (3) minority status and language; and (4) housing and transportation. Food deserts were defined as neighborhoods located 1 or 10 miles from a grocery store in urban and rural areas, respectively. Multiple regression analyses were performed to determine an association with LOS and cost, after controlling for demographics. Results. Increased 30-day COC associated with SVI theme 3, (3.074 days; p=0.001) and patients who lived in a food desert ($53,205; p=0.001), as well as those who had anemia ($16,112; P = 0.038),
Recent studies have described safe outcomes for short-stays in the hospital after total shoulder arthroplasty. The purpose of this study is to identify pre-operative and operative risk factors for hospital admissions exceeding 24 hours. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried from 2006 to 2016 for the current procedural terminology (CPT) billing code related to total shoulder arthroplasty. Patients were then grouped as either having a length of stay (LOS) equal to or less than 24 hours or greater than 24 hours. Patients admitted to the hospital prior to the day of surgery were excluded. Patient demographics, co-morbidities, and operative time were then analyzed as risk factors for a hospital stay exceeding 24 hours. Pre-operative co-morbidities included body mass index (BMI), diabetes, smoking,
Total hip arthroplasty (THA) continues moving to the outpatient arena, and may be feasible for some conversion and revision scenarios. Controversy surrounds appropriate patient selection. The purpose of this study is to report complications associated with outpatient revision and conversion THA, and to determine if comorbidities are associated with complications or overnight stay. From June 2013 through March 2018, 43 patients (44 hips) underwent conversion (n=9) or revision (n=35) THA at a free-standing ambulatory surgery center. Mean patient age was 58.4 years, and 52% of patients were male. Conversion procedures were failed fracture fixation with retained hardware and all involved both femoral and acetabular replacement. Revision procedures involved head only in one, head and liner in 20, cup and head in 8, stem only in one, stem and liner in 4, and full revision in one. Forty-one (93%) were discharged same day without incident, none required transfer to acute facility, and 3 required overnight stay with 2 of these for convenience and only one for a medical reason, urinary retention. Three patients with early superficial infection, including 2 diagnosed by positive intraoperative cultures, were successfully treated with oral antibiotics. There were no major complications, readmissions, or subsequent surgeries within 90 days. One or more major comorbidities were present in 15 patients (34%) including 1 valvular disease, 7 arrhythmia, 2 thromboembolism history, 3 obstructive sleep apnea, 3
Total hip arthroplasty (THA) continues moving to the outpatient arena, and may be feasible for some conversion and revision scenarios. Controversy surrounds appropriate patient selection. The purpose of this study is to report complications associated with outpatient revision and conversion THA, and to determine if comorbidities are associated with complications or overnight stay. From June 2013 through March 2018, 43 patients (44 hips) underwent conversion (n=12) or revision (n=32) THA at a free-standing ambulatory surgery center. Mean patient age was 58.4 years, and 52% of patients were male. Conversion procedures were for failed resurfacing in two, failed hemiarthroplasty in one, and failed fracture fixation with retained hardware in 9. Revision procedures involved head only in one, head and liner in 20, cup and head in 7, stem only in 2, and stem and liner in 2. Forty-four (93%) were discharged same day without incident, none required transfer to acute facility, and 3 required overnight stay with 2 of these for convenience and only one for a medical reason, urinary retention. Three patients with early superficial infection were successfully treated with oral antibiotics. There were no major complications, readmissions, or subsequent surgeries within 90 days. One or more major comorbidities were present in 17 patients (39%) including 1 valvular disease, 8 arrhythmia, 2 thromboembolism history, 3 obstructive sleep apnea, 6
Purpose. The purpose of this study was to evaluate the effect of common medical comorbidities on the reimbursements of different shoulder arthroplasty procedures. Methods. We conducted a retrospective query of a private payer insurance claims database of prospectively collected data (PealDiver). Our search included the Current Procedural Terminology Codes (CPT) and International Classification of Disease (ICD) ninth edition codes for Total Shoulder Arthroplasty (TSA), Hemiarthroplasty (HA) and Reverse Shoulder Arthroplasty (RSA). Medical comorbidities were also searched for through ICD codes. The comorbidities selected for analysis were obesity, morbid obesity, hypertension, smoking, diabetes mellitus, hyperlipidemia, atrial fibrillation,
Over 300,000 total hip arthroplasties (THA) are performed annually in the USA. Surgical Site Infections (SSI) are one of the most common complications and are associated with increased morbidity, mortality and cost. Risk factors for SSI include obesity, diabetes and smoking, but few studies have reported on the predictive value of pre-operative blood markers for SSI. The purpose of this study was to create a clinical prediction model for acute SSI (classified as either superficial, deep and overall) within 30 days of THA based on commonly ordered pre-operative lab markers and using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. All adult patients undergoing an elective unilateral THA for osteoarthritis from 2011–2016 were identified from the NSQIP database using Current Procedural Terminology (CPT) codes. Patients with active or chronic, local or systemic infection/sepsis or disseminated cancer were excluded. Multivariate logistic regression was used to determine coefficients, with manual stepwise reduction. Receiver Operating Characteristic (ROC) curves were also graphed. The SSI prediction model included the following covariates: body mass index (BMI) and sex, comorbidities such as congestive heart failure (CHF),
Hip fractures are among the most common orthopaedic injuries and represent a growing burden on healthcare as our population ages. Despite improvements in preoperative optimisation, surgical technique and postoperative care, complication rates remain high. Time to surgery is one of the few variables that may be influenced by the medical team. The aim of the present study was to evaluate the impact of time to surgery on mortality and major complications following surgical fixation of hip fractures. Utilising the American College of Surgeons' National Quality Improvement Program (NSQIP) database, we analysed all hip fractures (femoral neck, inter-trochanteric, and sub-trochanteric) treated from 2011 to 2013 inclusively. We divided patients into three groups based on time to surgery: less than one day (<24h), one to two days (24–48h), and two to five days (48–120h). Baseline characteristics were compared between groups and a multivariate analysis performed to compare 30-day mortality and major complications (return to surgery, deep wound infection, pneumonia, pulmonary embolus, acute renal failure, cerebrovascular accident, cardiac arrest, myocardial infarction, or coma) between groups. A total of 14,730 patients underwent surgical fixation of a hip fracture and were included in our analysis. There were 3,475 (24%) treated <24h, 9,960 (67%) treated 24–48h, and 1,295 (9%) treated 48–120h. Thirty-day mortality and major complication rates were 5.0% and 6.2% for the <24h group, 5.3% and 7.0% for the 24–48h group, 7.9% and 9.7% for the 48–120h group respectively. After controlling for baseline demographic differences between groups (age, sex, race) as well as pertinent comorbidities (diabetes, dyspnea,
Total knee arthroplasty (TKA) is the most commonly performed elective orthopaedic procedure. With an increasingly aging population, the number of TKAs performed is expected to be ∼2,900 per 100,000 by 2050. Surgical Site Infections (SSI) after TKA can have significant morbidity and mortality. The purpose of this study was to construct a risk prediction model for acute SSI (classified as either superficial, deep and overall) within 30 days of a TKA based on commonly ordered pre-operative blood markers and using audited administrative data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. All adult patients undergoing an elective unilateral TKA for osteoarthritis from 2011–2016 were identified from the NSQIP database using Current Procedural Terminology (CPT) codes. Patients with active or chronic, local or systemic infection/sepsis or disseminated cancer were excluded. Multivariate logistic regression was conducted to estimate coefficients, with manual stepwise reduction to construct models. Bootstrap estimation was administered to measure internal validity. The SSI prediction model included the following co-variates: body mass index (BMI) and sex, comorbidities such as congestive heart failure (CHF),
To progress to a same day surgery program for arthroplasty, it is important that we examine and resolve the issues of why patients stay in the hospital. The number one reason is fear and anxiety of the unknown and of surgical pain. The need for hospital stay is also related to risk arising from comorbidities and medical complications. Patients also need an extended stay to manage the side effects of our treatment, including after effects of narcotics and anaesthesia, blood loss, and surgical trauma. The process begins pre-operatively with an appropriate orthopaedic assessment of the patient and determination of the need for surgery. The orthopaedic team must motivate the patient, and ensure that the expectations of the patient, family and surgeon are aligned. In conjunction with our affiliated hospitalist group that performs almost all pre-admission testing, we have established guidelines for patient selection for outpatient arthroplasty. The outpatient surgical candidate must have failed conservative measures, must have appropriate insurance coverage, and must be functionally independent. Previous or ongoing comorbidities that cannot be optimised for safe outpatient care may include: congestive heart failure, or valve
Purpose: The comorbidities currently considered to increase surgical risk, particularly in the elderly, include heart disorders, diabetes, asthma, obesity, and
