The Effect of Fixation Type on Periprosthetic Fractures in High-Risk Patients Who have Osteoporosis Undergoing Total Joint Arthroplasty

Abstract

IntroductionMinimizing the burden of periprosthetic fractures (PFF) following total joint arthroplasty (TJA) with regard to morbidity and mortality remains an outcome of interest. Patient and surgical risk factors, including osteoporosis and fixation type, have not truly been optimized in patients undergoing TJA as a means to reduce the risk of PFF. As such, we examined: (1) What percentage of patients who underwent THA and total knee arthroplasty (TKA) met the criteria for osteoporosis screening? (2) How did the 5-year rate of PFF and fragility fracture differ in the high-risk and low-risk groups for osteoporosis between the cemented and cementless cohorts? (3) What percentage of the aforementioned patients received a dual x-ray absorptiometry (DEXA) scan before THA or TKA? MethodsWe queried an all-payer, national database from April 1, 2016 to December 31, 2021, to identify high-risk and low-risk patients who underwent TJA with a cementless or cemented fixation. High-risk patients met at least one of the following criteria: men at least 70 years old, women at least 65 years old, or patients at least 60 years old who have the following: tobacco use, alcohol abuse, body mass index < 18.5, prior fragility fracture, chronic systemic corticosteroids, or genetic condition affecting sex hormones or bone mineral density. Exclusion criteria were a diagnosis of malignancy, high-energy events (motor vehicle collision), those who underwent TJA indicated for fracture, patients less than 50 years old, those who had a prior diagnosis of or treatment for osteoporosis, and a minimum follow-up of less than 2 years. ResultsThere were 384,783 patients (67.1%) who underwent cementless TKA and 67,774 patients (11.8%) who underwent cementless TKA who were considered high risk. Additionally, there were 62,505 patients (10.9%) who underwent cemented THA and 58,667 patients (10.2%) who underwent cementless THA and were considered high risk. The cementless cohort had a 5-year periprosthetic fracture risk following TKA of 7.8% (95% CI, 5.56 to 10.98) in comparison to 4.30% in the cemented cohort (85% CI, 3.98 to 4.65), P <0.0001. The high-risk cementless cohort had a 5-year periprosthetic fracture risk following THA of 7.9% (95% confidence interval (CI), 6.87 to 9.19) in comparison to 7.78% in the cemented cohort (85% CI, 6.77 to 8.94), P <0.0001. ConclusionThere is an increased risk of PFF at 5 years following TKA in patients at high risk for osteoporosis undergoing cementless fixation in comparison to cemented fixation. There is an increased risk of PFF at 5 years following THA in patients at high risk for osteoporosis for both cementless fixation and cemented fixation, but no clinically meaningful difference between the two groups. Addressing the shortcomings of the underutilization of bone density scans and better selecting appropriate patients for TJA based on bone quality and fracture risk can help expedite the process of improving the current state of practice.