Orthopedics

Feature Article 

Risk Factors for Wound Complications After Periprosthetic Fractures

Eli Kamara, MD; Zachary P. Berliner, MD; H. John Cooper, MD

Abstract

The number of hip and knee arthroplasties performed annually continues to rise. Revision rates are projected to increase by 137% to 601%, with periprosthetic fractures to be among the leading cause of revision. Wound complications following surgical treatment of periprosthetic fractures are a major source of patient morbidity and health care costs. This study evaluated risk factors for wound healing complications in patients undergoing surgical management of periprosthetic fractures around the hip and knee. This was a retrospective analysis of 67 consecutive lower-extremity periprosthetic hip and knee fracture surgeries. Descriptive data, comorbidities, dressing type, and rates of wound complications treated nonoperatively and operatively were collected. Logistic regression analysis was performed to calculate odds ratios (ORs) of having a wound complication. There was an overall wound complication rate of 22%; the majority of these complications (16%) were treated operatively. On multivariate analysis, prior bariatric surgery (OR, 12.02; 95% confidence interval [CI], 1.24–116.71; P=.03), peripheral vascular disease (OR, 6.84; 95% CI, 1.32–35.39; P=.02), and pulmonary disease (OR, 11.23; 95% CI, 1.85–68.31; P=.01) were all associated with an increased risk of developing a wound complication. Closed-incision negative-pressure therapy was associated with a decreased risk of developing a wound complication (OR, 0.04; 95% CI, 0.00–0.49, P=.01). Surgery to treat hip and knee periprosthetic fractures is associated with a high rate of wound complications. History of bariatric surgery, peripheral vascular disease, and pulmonary disease are all associated with an increased risk of developing a wound complication. Future payment models should reflect this elevated level of complications and risk. [Orthopedics. 2020;43(4):e258–e262.]

Abstract

The number of hip and knee arthroplasties performed annually continues to rise. Revision rates are projected to increase by 137% to 601%, with periprosthetic fractures to be among the leading cause of revision. Wound complications following surgical treatment of periprosthetic fractures are a major source of patient morbidity and health care costs. This study evaluated risk factors for wound healing complications in patients undergoing surgical management of periprosthetic fractures around the hip and knee. This was a retrospective analysis of 67 consecutive lower-extremity periprosthetic hip and knee fracture surgeries. Descriptive data, comorbidities, dressing type, and rates of wound complications treated nonoperatively and operatively were collected. Logistic regression analysis was performed to calculate odds ratios (ORs) of having a wound complication. There was an overall wound complication rate of 22%; the majority of these complications (16%) were treated operatively. On multivariate analysis, prior bariatric surgery (OR, 12.02; 95% confidence interval [CI], 1.24–116.71; P=.03), peripheral vascular disease (OR, 6.84; 95% CI, 1.32–35.39; P=.02), and pulmonary disease (OR, 11.23; 95% CI, 1.85–68.31; P=.01) were all associated with an increased risk of developing a wound complication. Closed-incision negative-pressure therapy was associated with a decreased risk of developing a wound complication (OR, 0.04; 95% CI, 0.00–0.49, P=.01). Surgery to treat hip and knee periprosthetic fractures is associated with a high rate of wound complications. History of bariatric surgery, peripheral vascular disease, and pulmonary disease are all associated with an increased risk of developing a wound complication. Future payment models should reflect this elevated level of complications and risk. [Orthopedics. 2020;43(4):e258–e262.]

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are two of the most commonly performed operations in the United States. There are approximately 7 million Americans living with an artificial joint replacement.1 During the next 15 years, the number of arthroplasty cases performed is predicted to increase 85% and 71% for TKA and THA, respectively, with similar trends projected worldwide.2–5 As more arthroplasties are performed in younger and more active patients, revision rates are predicted to increase by 137% to 601%.6

Currently, periprosthetic fractures account for a relatively small amount of the revision arthroplasty burden. Fracture is the primary diagnosis in approximately 1% to 6% of all revision arthroplasties, with fractures around a THA having a slightly higher incidence compared with TKA.6,7 These rates are projected to increase and be among the leading causes of revision in the future.6 These fractures also carry a significantly large cost per episode of care and are an economic burden on the health care system, costing in many instances more than $50,000 USD per episode of care due to the increasing complexity and comorbidities of these patients.8

Revision arthroplasty for fracture is associated with higher complication rates than primary surgery, including markedly elevated risks of wound complications, deep infection, and return to the operating room.9,10 The 1-year reoperation rate has been reported to range between 12% and 32%,9–13 and the surgical-site infection (SSI) rate ranges between 9% and 26%.9,10,13–15 Although specific risk factors for infection and wound healing complications have been well defined in primary arthroplasty,16,17 data are lacking in the setting of periprosthetic fracture surgery. The aim of this study was to determine the risk factors for wound healing complications in a cohort of patients undergoing surgical management of periprosthetic fractures around the hip and knee.

Materials and Methods

Patients

The authors previously identified a cohort of 69 consecutive patients who underwent operative management of a periprosthetic fracture at a single institution between January 2010 and July 2016.13 In this cohort, 1 patient died as an inpatient on postoperative day 17, and 1 patient was lost to follow-up prior to documentation of successful wound healing. These 2 patients were excluded, leaving 67 (97.1%) of 69 patients with adequate clinical follow-up. Institutional review board approval was obtained before initiation of the study.

Surgical Technique

All surgeries were performed by 1 of 4 fellowship-trained surgeons who held a subspecialty practice in either orthopedic traumatology or adult hip and knee reconstruction. The surgical technique varied based on the fracture type and location and stability of the prosthesis. Vancouver A(G), B1, and C femur fractures were treated with component retention and open reduction and internal fixation (ORIF). Vancouver B2 and B3 femur fractures were treated with femoral stem revision with concurrent ORIF. Acetabular fractures were treated with cup revision and concurrent ORIF or placement of a cup-cage construct. Supracondylar femur fractures above a TKA were treated with ORIF, retrograde intramedullary nailing, or component revision depending on fracture pattern and stability of the prosthesis. Surgical incisions were closed primarily at the time of the initial surgery according to the preference of the treating surgeon, and methodology was not consistent. Postoperative dressing applied sterilely in the operating theater was either an Aquacel Ag surgical dressing (Convatec, Greensboro, North Carolina) or closed-incision negative-pressure therapy (NPT) using the Prevena incision management system (KCI, San Antonio, Texas) as per provider preference.

Outcomes

The primary outcome of the study was any wound complication, using previously defined criteria.13,16,18 These include both wound complications that were treated nonoperatively, such as superficial SSIs, prolonged drainage, and wound dehiscence, as well as those treated operatively, including more aggressive superficial SSIs and deep infection. Demographics, comorbidities, approach, and surgery type were collected in a database.

Statistical Analysis

Univariate regression analysis was performed with SPSS software (IBM, Armonk, New York) to calculate odds ratios (ORs). Variables with P≤.15 were included in the multivariate regression model.

Results

Patient demographics are presented in Table 1. The majority of fractures treated were in the femur (90%), and the main procedures were revision of a femoral component of a THA (33%), revision of both components of a THA (15%), and ORIF of a femoral shaft fracture (15%). The lateral and posterior approaches were used for 49 (73%) patients (Table 2). Fifteen (22%) patients had a wound complication in the postoperative period. Of these patients, 11 (16%) required return to the operating room to address this wound complication (Figure 1). Ten (15%) of these return trips to the operating room were for a deep infection. Four (6%) patients had complications treated nonoperatively.

Cohort Characteristics

Table 1:

Cohort Characteristics

Surgical Details

Table 2:

Surgical Details

Flow chart of diagnosis by treatment method.

Figure 1:

Flow chart of diagnosis by treatment method.

On univariate analysis (Table 3), a history of peripheral vascular disease (PVD) (OR, 3.68; 95% confidence interval [CI], 1.08–12.53; P=.04) and a history of pulmonary disease (OR, 5.63; 95% CI, 1.55–20.43; P=.01) were found to be significantly associated with the development of wound complications, whereas a history of prior bariatric surgery approached statistical significance. Surgical approach and type of revision were not associated with a risk of wound complications and was excluded from the multivariate model. The use of closed-incision NPT was protective against the development of wound complications (OR, 0.07; 95% CI, 0.01–0.58; P=.01). Although this finding specific to closed-incision NPT was previously published in the authors' prior study,13 it was left in the data analysis to control for its use as a potential confounding variable. With the numbers available, the authors did not find associations between the development of wound complications and age, sex, American Society of Anesthesiologists classification, smoking status, or a history of obesity or diabetes mellitus.

Univariate Logistic Regression

Table 3:

Univariate Logistic Regression

On multivariate analysis (Table 4), a history of PVD and pulmonary disease remained associated with the development of wound complications, and prior bariatric surgery became statistically significant (OR, 12.02; 95% CI, 1.24–116.71; P=.03). Additionally, the use of closed-incision NPT remained protective against the development of wound complications on the multivariate analysis (OR, 0.04; 95% CI, 0.00–0.49; P=.01).

Multivariate Logistic Regression

Table 4:

Multivariate Logistic Regression

Discussion

Periprosthetic fractures are challenging injuries to treat and are associated with significant patient morbidity. Surgical-site infections and incisional complications are among the leading causes for reoperation after treating these injuries.9,10,15 This study found a wound complication rate of 22%, with 16% requiring at least 1 return to the operating room for debridement, revision closure, or component revision because of the wound complications. Patients with a history of vascular disease, pulmonary disease, and prior bariatric surgery were significantly more likely to have 1 of these wound complications, whereas the use of closed-incision NPT was associated with a decreased risk for developing a wound complication.

Although the authors' wound complication rate of 22% and reoperation rate of 16% are consistent with previously reported values that range from 9% to 26% for SSI9,10,14,15,19 and 12% to 32% for re-operation,9–13 they are significantly higher compared with the rates found in primary arthroplasty. One registry study found an incidence of 0.33% in more than 17,000 primary TKAs.20 The high rate of wound complications after periprosthetic fracture surgery is likely related to both the procedure and the patient. Revision surgery is inherently more invasive than primary arthroplasty, often requiring a larger and more extensive exposure with concurrent soft tissue disruption. Additionally, the patients who have these fractures are typically older and tend to have more comorbidities.8

Similar to the findings in the current study, PVD has been associated with the development of wound complications in primary joint arthroplasty.20 Few other studies report on the incidence of wound complications in patients with PVD or pulmonary disease having an arthroplasty, but a larger rate of general complications has been reported in two separate registry studies.21,22 This is in contrast to the large amount of data associating increasing body mass index (BMI) with wound complications. One large cohort study of nearly 1000 arthroplasty patients found BMI to be a risk factor for superficial wound complications.17 Two recent studies from the National Surgical Quality Improvement Program (NSQIP) database with more than 150,000 patients in each cohort found BMI to be associated with an increased risk of superficial wound infections and wound dehiscence with primary arthroplasty.23,24 The lack of association in the current study may be a type II error but may also be explained when controlling for a history of gastric bypass. Gastric bypass patients are at high risk for malnutrition.25 Malnutrition has been associated with a higher rate of SSIs, postoperative complications, and even mortality in the NSQIP database.26–28 The current study confirms these observations in post-bariatric surgery patients having revision surgery for periprosthetic fractures.

Limitations of this study included its retrospective observational design and small sample that was likely underpowered to assess the effect of each comorbidity. Additionally, the small number of complications made the study prone to type II errors. Although the authors found no significant associations between wound complications and smoking, many data support this association.29–31 The study results trended toward an association but failed to reach statistical significance, likely representing a type II error due to the small sample. A strong protective effect with NPT against wound complications was observed and has been published in detail elsewhere,13,18 but given the observational study design, treatment effect bias has likely been introduced. A large retrospective trial recently found similar benefits in primary arthroplasty patients32; however, the literature in this area has demonstrated inconsistent results, and further research is required on this topic.22

Conclusion

This study confirmed previously published results that surgery to treat periprosthetic fractures following THA and TKA is associated with a high rate of wound complications and identified specific comorbidities that further elevate this risk. Future payment models should reflect this elevated level of complications and risk. Future studies should be directed at investigating the potential protective effects of NPT in this high-risk population.

References

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Cohort Characteristics

CharacteristicValue
Sex, No.
  Female44 (66%)
  Male23 (34%)
Age, mean (range), y74 (43–91)
Follow-up, mean (range), mo14 (1–61)
American Society of Anesthesiologists classification >2, No.35 (52%)
Diabetes mellitus, No.9 (13%)
History of gastric bypass, No.5 (7%)
Negative-pressure wound therapy, No.26 (39%)
Obesity (body mass index >30 kg/m2), No.24 (36%)
Peripheral vascular disease, No.17 (25%)
Pulmonary disease, No.14 (21%)
Smoking history, No.7 (10%)

Surgical Details

ParameterNo.No. of Complications
Surgery by fracture type
  Acetabulum4 (6%)1
  Distal femur15 (22%)3
  Femoral shaft23 (34%)6
  Proximal femur22 (33%)5
  Tibia3 (4%)0
Surgery by approach
  Total hip arthroplastya54 (81%)14
    Anterior5 (7%)0
    Lateral15 (22%)6
    Posterior34 (51%)8
  Total knee arthroplastya13 (19%)1
    Medial parapatellar11 (16%)0
    Midvastus2 (3%)1

Univariate Logistic Regression

Patient CharacteristicOdds Ratioa (95% Confidence Interval)P
Age (continuous)1.00 (0.95–1.05).92
American Society of Anesthesiologists classification >21.50 (0.47–4.82).50
Diabetes mellitus0.39 (0.05–3.42).40
Female2.50 (0.63–10.00).19
History of gastric bypass6.25 (0.94–41.68).06
Negative-pressure wound therapy0.07 (0.01–0.58).01b
Obesity (body mass index >30 kg/m2)1.26 (0.39–4.10).70
Peripheral vascular disease3.68 (1.08–12.53).04b
Pulmonary disease5.63 (1.55–20.43).01b
Smoking history1.45 (0.25–8.33).68

Multivariate Logistic Regression

Patient CharacteristicOdds Ratioa (95% Confidence Interval)P
History of gastric bypass12.02 (1.24–116.71).03b
Negative-pressure wound therapy0.04 (0.00–0.49).01b
Pulmonary disease11.23 (1.85–68.31).01b
Peripheral vascular disease6.84 (1.32–35.39).02b
Authors

The authors are from the Department of Orthopaedic Surgery (EK), Albert Einstein College of Medicine, Bronx, the Department of Orthopaedic Surgery (ZPB), Lenox Hill Hospital, New York, and the Department of Orthopaedic Surgery (HJC), Columbia University, New York, New York.

Drs Kamara and Berliner have no relevant financial relationships to disclose. Dr Cooper is a paid consultant for KCI, Zimmer Biomet, DePuy, and Corin and has received grants from Smith & Nephew.

Correspondence should be addressed to: H. John Cooper, MD, Department of Orthopaedic Surgery, Columbia University, 161 Fort Washington Ave, New York, NY 10032 ( hjc2008@cumc.columbia.edu).

Received: January 15, 2019
Accepted: April 22, 2019
Posted Online: April 23, 2020

10.3928/01477447-20200415-01

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