Total Hip Arthroplasty In Elderly Patients Research Articles

RECTANGULAR TAPER STEM DESIGNS ARE ASSOCIATED WITH A HIGHER RISK FOR PERIPROSTHETIC FEMORAL FRACTURES AFTER CEMENTLESS TOTAL HIP ARTHROPLASTY

Periprosthetic femoral fractures (PFFs) remain a major concern following cementless total hip arthroplasty (THA). This study aimed to evaluate the association between different types of cementless tapered stems and the risk of postoperative PFF.A retrospective review of primary THAs performed at a single center from January 2011 to December 2018 included 3,315 hips (2,326 patients). Cementless stems were classified according to their design geometry using the system proposed by Radaelli et al. The incidence of PFF was compared between flat taper porous-coated stems (type A), rectangular taper grit-blasted stems (type B1), and quadrangular taper hydroxyapatite-coated stems (type B2). Multivariate regression analyses were performed to identify independent factors related to PFF. The mean follow-up duration was 61 months (range, 12‒139 months).Overall, 45 (1.4%) postoperative PFFs occurred. The incidence of PFF was significantly higher in type B1 stems than in type A and type B2 stems (1.8 vs. 0.7 vs. 0.7%; P=0.022). Additionally, more surgical treatments (1.7 vs. 0.5 vs. 0.7%; P=0.013) and femoral revisions (1.2 vs. 0.2 vs. 0%; P=0.004) were required for PFF in type B1 stems. After controlling for confounding variables, older age (P<0.001), diagnosis of hip fracture (P<0.001), and use of type B1 stems (P=0.001) were significant factors associated with PFF.Type B1 rectangular taper stems were found to have higher risks for postoperative PFF and PFF requiring surgical management than type A and type B2 stems in THA. Femoral stem geometry should be considered when planning for cementless THA in elderly patients with compromised bone quality.

Comparative Interrupted Time Series Analysis of Direct Medical Expense and Length of Stay in Elderly Patients with Femoral Neck Fractures Who Underwent Total Hip Arthroplasty and Hemiarthroplasty: A Real World Nationwide Database Study.

The objective of our study was to analyze the postoperative direct medical expenses and hospital lengths of stay (LOS) of elderly patients who had undergone either hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fractures and to determine the indication of THA by comparing those variables between the 2 groups by time. In this comparative large-sample cohort study, we analyzed data from the 2011 to 2018 Korean National Health Insurance Review and Assessment Service database. The included patients were defined as elderly individuals aged 60 years or older who underwent HA or THA for a femoral neck fracture. A 1:1 risk-set matching was performed on the propensity score, using a nearest-neighbor matching algorithm with a maximum caliper of 0.01 of the hazard components. In comparative interrupted time series analysis, time series were constructed using the time unit of one-quarter before and after 3 years from time zero. For the segmented regression analysis, we utilized a generalized linear model with a gamma distribution and logarithmic link function. A total of 4,246 patients who received THA were matched and included with 4,246 control patients who underwent HA. Although there was no statistically significant difference in direct medical expense and hospital LOS for the first 6 months after surgery, direct medical expenses and hospital LOS in THA were relatively reduced compared to the HA up to 24 months after surgery (p < 0.05). In the subgroup analysis, the THA group's hospital LOS decreased significantly compared to that of the HA group during the 7 to 36 months postoperative period in the 65 ≤ age < 80 age group (p < 0.05). Direct medical expenses of the THA group significantly decreased compared to those of the HA group during the period from 7 to 24 months after surgery in the men group (p < 0.05). When performing THA in elderly patients with femoral neck fractures, the possibility of survival for at least 2 years should be considered from the perspective of medical expense and medical utilization. Additionally, in healthy and active male femoral neck fracture patients under the age of 80 years, THA may be more recommended than HA.

How Much Protection Does a Collar Provide? Assessing Risk of Early Periprosthetic Femur Fractures Following Total Hip Arthroplasty in Elderly Patients

BackgroundPeriprosthetic fractures (PPFs) account for approximately 25% of early revisions following total hip arthroplasty (THA). Cemented femoral fixation is associated with a lower-risk of PPF, and collared-cementless stems may reduce the risk as well. The objective of this study was to compare early-PPF rates between cemented, collared-cementless, and non-collared cementless stems in elderly patients. MethodsA consecutieve-series of 11,522 primary THAs performed between 2016 and 2021 at our institution in patients >65 years of age was identified. Stem types used were categorized as cemented, collared-cementless, or non-collared cementless. Patients undergoing THA who had cemented-stems were older, more commonly women, and more likely to have a posterior-approach. To reduce confounding of patient characteristics, we matched patients in the 3 stem-categories according to age, sex, and body mass index. This generated 3-groups (cemented, collared-cementless, and non-collared cementless) consisting of 936 patients per group. The mean age of these 2,808 patients was 73 years, the mean body mass index was 27, and 67% were women. Logistic regressions were used to evaluate risk-factors for early-PPF. In the entire cohort of primary THA in elderly patients, there were 85 early PPFs (0.7%) over the study period. ResultsNon-collared cementless stems were associated with an increased risk of early PPF (OR: 3.11; P = .03) compared to collared-cementless stems. There were no early PPFs in the matched cemented cohort, 6 early PPFs in the matched collared-cementless cohort, and 16 early-PPFs in the matched non-collared cementless cohort (0% versus 0.64% versus 1.71%, P < .001). ConclusionsIn this large-series of patients >65 years of age undergoing primary THA, cemented stem fixation had the lowest incidence of early PPF, but collared-cementless stems had a nearly 3-fold decrease in risk for early PPF compared to non-collared cementless stems.

Risk Factors and Predictors for Functional Outcome and Complication Rate in Total Hip Arthroplasty through Minimally Invasive and Conventional Approaches: A Systematic Review and Meta-Regression Analysis of 41 Randomized Controlled Trials.

To investigate and identify risk factors and predictors for the difference in functional outcome and complications between total hip arthroplasty (THA) through minimally invasive and conventional approaches, using a meta-regression analysis of randomized controlled trials (RCTs). A systematic review of the literature up to 31 July 2022 was performed. A meta-regression was conducted based on a random effects meta-analysis using the Hartung-Knapp-Sidik-Jonkman method. A total of 41 RCTs with 3607 patients were found. The following predictors of HHS ≥ 6 months postoperatively were identified: patient age (predictor estimate = 0.14; p < 0.01), avascular necrosis of the femoral head (predictor estimate = -0.03; p = 0.04); incision length (predictor estimate = -0.82; p < 0.01). The following predictors of complication rate were identified: osteoarthritis (predictor estimate = 0.02; p = 0.02); femoral neck fracture (predictor estimate = -0.02; p = 0.02); SuperPATH (predictor estimate = -1.72; p < 0.01). Patient age, avascular necrosis of the femoral head, and incision length were identified as predictors of the effect size of the HHS ≥ 6 months postoperatively; and osteoarthritis, femoral neck fracture, and SuperPATH as predictors of the effect size of the complication rate. Based on these findings, we recommend that more frequent use of minimally invasive THA in elderly patients should be considered. a systematic review of all relevant randomized controlled trials. Registered in PROSPERO on 10 August 2022 (CRD42022350287).

Rectangular Taper Stem Designs Are Associated With a Higher Risk for Periprosthstic Femoral Fractures After Cementless Total Hip Arthroplasty

BackgroundPeriprosthetic femoral fractures (PFFs) remain a major concern following cementless total hip arthroplasty (THA). This study aimed to evaluate the association between different types of cementless tapered stems and the risk of postoperative PFF. MethodsA retrospective review of primary THAs performed at a single center from January 2011 to December 2018 included 3,315 hips (2,326 patients). Cementless stems were classified according to their design. The incidence of PFF was compared between flat taper porous-coated stems (type A), rectangular taper grit-blasted stems (type B1), and quadrangular taper hydroxyapatite-coated stems (type B2). Multivariate regression analyses were performed to identify independent factors related to PFF. The mean follow-up duration was 61 months (range, 12 to 139). Overall, 45 (1.4%) postoperative PFFs occurred. ResultsThe incidence of PFF was significantly higher in type B1 stems than in type A and type B2 stems (1.8 versus 0.7 versus 0.7%; P = .022). Additionally, more surgical treatments (1.7 versus 0.5 versus 0.7%; P = .013) and femoral revisions (1.2 versus 0.2 versus 0%; P = .004) were required for PFF in type B1 stems. After controlling for confounding variables, older age, diagnosis of hip fracture, and use of type B1 stems were significant factors associated with PFF. ConclusionType B1 rectangular taper stems were found to have higher risks for postoperative PFF and PFF requiring surgical management than type A and type B2 stems in THA. Femoral stem geometry should be considered when planning for cementless THA in elderly patients who have compromised bone quality.

The Feasibility of Using the Direct Anterior Approach for Total Hip Arthroplasty or Bipolar Hemiarthroplasty to Treat Femoral Neck Fractures among the Elderly.

Purpose Femoral neck fractures (FNFs) are a significant cause of mortality and disability among the elderly. Total hip arthroplasty (THA) is the preferred treatment method in active, cognitively intact patients. In less active or cognitively impaired patients, bipolar hemiarthroplasty (BHA) is the practical option in Japan. Even with the direct anterior approach (DAA), clinical concerns about conducting THA in elderly patients include possible dislocations, critical complications, and medical cost-effectiveness. This study is aimed at rethinking the practical surgical indications for FNFs. Methods Between April 2019 and March 2021, BHA patients with displaced FNF (n = 21) performed through the DAA were compared with THA patients with displaced FNF (n = 19). The perioperative complications, clinical and radiologic outcomes, and mortality were compared between groups retrospectively at six months. Results THA patients had an increased average operation time (103.3 min vs. 89.1 min, P < 0.05) and similar amounts of bleeding (183.16 ml. vs. 121.1 ml.). The percentages of patients who received biological transfusion showed no difference, with low rates of perioperative complications (4% vs. 0%) and similar mortality rates compared to BHA patients. One THA patient experienced posterior dislocation during a state of postoperative delirium. Conclusion THA through the DAA might be a credible and safe option for FNF patients, with excellent functional outcomes and fewer surgery-related complications. Early posterior dislocation might be related to optimized offset distance and not related to leg discrepancy or other radiographic items. Hence, orthopedic surgeons should reconsider their options before conducting BPH for elderly and cognitively intact FNF patients.

Influencing Factors for Infection in Elderly Patients After Total Hip Arthroplasty

Objective: To explore the influencing factors for infection in elderly patients after total hip arthroplasty (THA) using logistic regression analysis. Methods: A total of 162 patients undergoing THA were selected, and their clinical data were retrospectively analyzed. The surgical treatment outcomes and postoperative conditions were recorded. They were divided into infection group (n=32) and non-infection group (n=130). The influencing factors for postoperative infection were analyzed by univariate and multivariate logistic regression analyses. A nomogram prediction model was established and validated. Results: Among the 162 elderly patients, postoperative infection occurred in 32 cases, with an infection rate of 19.75%. A total of 82 strains of pathogenic bacteria were isolated, including 48 strains of Gram-positive bacteria (58.5%) and 34 strains of Gram-negative bacteria (41.5%). There were significant differences in age, long-term use of hormones, history of hip surgery, serum albumin, procalcitonin (PCT), erythrocyte sedimentation rate (ESR), neutrophil count and lymphocyte count between infection and non-infection groups (P&lt;0.05). Age &gt;70 years old, long-term use of hormones, history of hip surgery, serum albumin &lt;35 g/L, PCT &gt;44.74 ng/mL, ESR &gt;5.83 mm/h, neutrophil count &gt;2.57×109/L and lymphocyte count &gt;2.94×109/L were influencing factors. The nomogram prediction model had high predictive value. Conclusion: THA has obvious clinical treatment outcomes. Age &gt;70 years old, long-term use of hormones, history of hip surgery, serum albumin &lt;35 g/L, PCT &gt;44.74 ng/mL, ESR &gt;5.83 mm/h, neutrophil count &gt;2.57×109/L and lymphocyte count &gt;2.94×109/L were independent influencing factors for infection after THA in elderly patients.

Effect of subarachnoid anesthesia combined with propofol target-controlled infusion on blood loss and transfusion for posterior total hip arthroplasty in elderly patients.

Intravertebral and general anesthesia (GA) are two main anesthesia approaches but both have defects. This study was aimed to evaluate the effect of subarachnoid anesthesia combined with propofol target-controlled infusion (TCI) on blood loss and transfusion for total hip arthroplasty (THA) in elderly patients in comparison with combined spinal-epidural anesthesia (CSEA) or GA. Totally, 240 patients (aged ≥65 years, American Society of Anesthesiologists [ASA] I-III) scheduled for posterior THA were enrolled from September 1st, 2017 to March 1st, 2018. All cases were randomly divided into three groups to receive CSEA (group C, n = 80), GA (group G, n = 80), or subarachnoid anesthesia and propofol TCI (group T, n = 80), respectively. Primary outcomes measured were intra-operative blood loss, autologous and allogeneic blood transfusion, mean arterial pressure at different time points, length of stay in post-anesthesia care unit (PACU), length of hospital stay, and patient satisfaction degree. Furthermore, post-operative pain scores and complications were also observed. The difference of quantitative index between groups were analyzed by one-way analysis of variance, repeated measurement generalized linear model, Student-Newman-Keuls test or rank-sum test, while ratio index was analyzed by Chi-square test or Fisher exact test. Basic characteristics were comparable among the three groups. Intra-operative blood loss in group T (331.53 ± 64.33 mL) and group G (308.03 ± 64.90 mL) were significantly less than group C (455.40 ± 120.48 mL, F = 65.80, P < 0.001). Similarly, the autologous transfusion of group T (130.99 ± 30.36 mL) and group G (124.09 ± 24.34 mL) were also markedly less than group C (178.31 ± 48.68 mL, F = 52.99, P < 0.001). The allogenetic blood transfusion of group C (0 [0, 100.00]) was also significantly larger than group T (0) and group G (0) (Z = 2.47, P = 0.047). Except for the baseline, there were significant differences in mean arterial blood pressures before operation (F = 496.84, P < 0.001), 10-min after the beginning of operation (F = 351.43, P < 0.001), 30-min after the beginning of operation (F = 559.89, P < 0.001), 50-min after the beginning of operation (F = 374.74, P < 0.001), and at the end of operation (F = 26.14, P < 0.001) among the three groups. Length of stay in PACU of group T (9.41 ± 1.19 min) was comparable with group C (8.83 ± 1.26 min), and both were significantly shorter than group G (16.55 ± 3.10 min, F = 352.50, P < 0.001). There were no significant differences among the three groups in terms of length of hospitalization and post-operative visual analog scale scores. Patient satisfaction degree of group T (77/80) was significantly higher than group C (66/80, χ = 7.96, P = 0.004) and G (69/80, χ = 5.01, P = 0.025). One patient complained of post-dural puncture headache and two complained of low back pain in group C, while none in group T. Incidence of post-operative nausea and vomiting in group G (10/80) was significantly higher than group T (3/80, χ = 4.10, P = 0.043) and group C (2/80, χ = 5.76, P = 0.016). No deep vein thrombosis or delayed post-operative functional exercise was detected. Single subarachnoid anesthesia combined with propofol TCI seems to perform better than CSEA and GA for posterior THA in elderly patients, with less blood loss and peri-operative transfusion, higher patient satisfaction degree and fewer complications. chictr.org.cn: ChiCTR-IPR-17013461; http://www.chictr.org.cn/showproj.aspx?proj=23024.

The Cost-Effectiveness of Total Hip Arthroplasty in Patients 80 Years of Age and Older

BackgroundThis study investigates the cost-effectiveness of total hip arthroplasty (THA) in patients 80 years old. MethodsA Markov, state-transition model projecting lifetime costs and quality-adjusted life years (QALYs) was constructed to determine cost-effectiveness from a societal perspective. Costs (in 2016 US dollars), health state utilities, and state transition probabilities were obtained from published literature. Primary outcome was incremental cost-effectiveness ratio, with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to evaluate parameter assumptions. ResultsAt our base-case values, THA was cost-effective compared to non-operative treatment with a total lifetime accrued cost of $186,444 vs $182,732, and a higher lifetime accrued utility (5.60 vs 5.09). Cost per QALY for THA was $33,318 vs $35,914 for non-operative management, and the incremental cost-effectiveness ratio was $7307 per QALY. Sensitivity analysis demonstrated THA to be cost-effective with a utility of successful primary THA above 0.67, a peri-operative mortality risk below 0.14, and a risk of primary THA failure below 0.14. Analysis further demonstrated that THA is a cost-effective option below a base-rate mortality threshold of 0.19, corresponding to the average base-rate mortality of a 93-year-old individual. Markov cohort analysis indicated that for patients undergoing THA at age 80 there was an approximate 28% reduction in total lifetime long-term assisted living expenditure compared to non-operatively managed patients with end-stage hip osteoarthritis. ConclusionThe results of our model demonstrate that THA is a cost-effective option compared to non-operative management in patients ≥80 years old. This analysis may inform policy regarding THA in elderly patients.

Efficacy of celecoxib for acute pain management following total hip arthroplasty in elderly patients: A prospective, randomized, placebo-control trial.

The aim of the present study was to determine whether celecoxib is able to ameliorate pain intensity, provide a narcotic-sparing effect, achieve early ambulation and improve rehabilitation following total hip arthroplasty (THA) in elderly patients. Peri- and post-operative oral celecoxib was administered to verify the efficacy of celecoxib for acute pain management in a multimodal analgesic strategy. All 64 eligible patients were randomly allocated to either the celecoxib group, who took an oral 400 mg capsule of celecoxib peri-operatively and 200 mg per 12 h post-operatively for the first 5 days, or the control group, who were orally treated with a placebo capsule having the same appearance. A multimodal analgesic technique was used in which oral celecoxib or placebo capsule was combined with intravenous patient-controlled analgesia (PCA) morphine pump for peri- and post-operative pain management. Pain assessments were recorded at 6, 12, 24, 48 and 72 h, and 7 and 14 days after THA using the visual analog scale (VAS). PCA morphine consumption; 6, 12, 24 and 48-h post-operative Harris hip score (HHS); time interval until initial ambulation; rates of urinary retention and post-operative nausea and vomiting (PONV) within 72 h; and intra- and post-operative blood loss were also documented. The celecoxib and control groups comprised 34 and 30 patients, respectively. Baseline demographics were comparable between the two groups. The post-operative VAS in the celecoxib group was significantly lower than that in the control group at 12, 24, 48 and 72 h after THA. The post-operative HHS had no significant difference between the two groups, while the time interval until initial ambulation in the celecoxib group (4.5±1.2 days) was significantly less than that in the control group (5.83±2.04 days; P<0.05). Morphine consumption was significantly decreased in the celecoxib group when compared with the control group at 6, 12, 24 and 24 h. Although the 72-h post-operative rates of urinary retention and PONV were lower in the celecoxib group than in the control group, there were no significant differences in these rates between the two groups. The intra- or post-operative blood loss was not significantly different between groups. In conclusion, pre-and post-operative oral celecoxib in a multimodal analgesic strategy can achieve favorable pain relief, reduce opioid consumption, and provide earlier ambulation and improved rehabilitation when compared with PCA morphine alone following THA in elderly patients.

Changes of hemoglobin and hematocrit in elderly patients receiving lower joint arthroplasty without allogeneic blood transfusion.

Background:It has rarely been reported about the changes of hemoglobin (Hb) and hematocrit (Hct) in elderly patients receiving total knee arthroplasty (TKA) or total hip arthroplasty (THA). This study aimed to evaluate the changes of Hb and Hct after TKA or THA in elderly patients, and analyze its relationship with sex and type of arthroplasty.Methods:This is a prospective cohort study, including 107 patients receiving TKA or THA without allogeneic blood transfusion. There were 54 males and 53 females, with a mean age of 69.42 years. Levels of Hb and Hct were examined preoperatively and during the 6 months follow-up after operation.Results:Levels of Hb and Hct decreased postoperatively and reached their minimum points on postoperative day 4. Thereafter, Hb and Hct recovered to their preoperative levels within 6–12 weeks. No significant differences in the levels of Hb and Hct were noticed between different sexes. THA patients showed significantly greater drop in Hb and Hct than TKA patients in the first 4 days postoperatively (P < 0.05).Conclusions:Levels of Hb and Hct decreased during the first 4 days after arthroplasty and gradually returned to their normal levels within 6–12 weeks postoperatively. THA may be associated with higher postoperative blood loss than TKA.

Association Between Low Admission Norton Scale Scores and Postoperative Complications After Elective THA in Elderly Patients

The Norton scoring system is used by nurses to evaluate pressure ulcer risk. The authors have previously shown that low admission Norton scale scores (ANSS) are associated with postoperative complications other than pressure ulcers following hip fracture and spine fracture surgery in elderly patients. The purpose of this retrospective, cross-sectional study study was to determine whether low ANSS are associated with postoperative complications other than pressure ulcers following elective total hip arthroplasty (THA) in elderly patients. The medical charts of consecutive elderly (older than 65 years) patients admitted between February 2008 and November 2010 were studied for acute renal failure, cardiovascular events, confusion, pneumonia, pressure ulcers, urinary infection, urinary retention, venous thromboembolism, wound infection, and other complications. The final cohort included 166 patients (108 [65.1%] women; aged 75.2±6.4 years). Overall, 24 (14.5%) patients had low (16 or less) ANSS. Patients with low ANSS had significantly more postoperative complications other than pressure ulcers compared with patients with high ANSS (0.5±0.7 vs 0.2±0.4, respectively; P=.018). Binary regression analysis showed that low ANSS were independently associated with all postoperative complications other than pressure ulcers (P=.039). In addition to predicting pressure ulcer risk, the Norton scoring system may be used for predicting other postoperative complications in elderly patients following elective THA.

Revision Total Hip Arthroplasty Using a Tapered, Press-Fit Cementless Revision Stem in Elderly Patients

In elderly patients, osteoporosis can complicate revision total hip arthroplasty (THA). The SLR-Plus (Smith & Nephew, Memphis, TN) revision stem has a tapered, press-fit design, which we hypothesized could enhance stability in this population. Accordingly, we retrospectively analyzed data for 48 elderly patients who underwent revision THA using the SLR-Plus stem. The patients had a mean age of 66.5 years (range, 60-81 years) at surgery. They were monitored for a mean of 5.6 years (range, 3.4-8.0 years) after surgery. The mean Harris Hip Score improved from 67.8 to 91.6. No infection, dislocation, osteolysis, or stress shielding around stem were observed after surgery. The survivorship at an average of 5.6-year follow-up was 98%. These favorable results indicate that the SLR-Plus stem is useful in revision THA in elderly patients.