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
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.
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.
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.
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.
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.
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
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
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
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.
- Maradit Kremers H, Larson DR, Crowson CS, et al. Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am. 2015;97(17):1386–1397. doi:10.2106/JBJS.N.01141 [CrossRef] PMID:26333733
- Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–785. doi:10.2106/JBJS.F.00222 [CrossRef] PMID: doi:10.2106/00004623-200704000-00012 [CrossRef]17403800
- Labek G, Thaler M, Janda W, Agreiter M, Stöckl B. Revision rates after total joint replacement: cumulative results from worldwide joint register datasets. J Bone Joint Surg Br. 2011;93(3):293–297. doi:10.1302/0301-620X.93B3.25467 [CrossRef] PMID:21357948
- Patel A, Pavlou G, Mujica-Mota RE, Toms AD. The epidemiology of revision total knee and hip arthroplasty in England and Wales: a comparative analysis with projections for the United States. A study using the National Joint Registry dataset. Bone Joint J. 2015;97-B(8):1076–1081. doi:10.1302/0301-620X.97B8.35170 [CrossRef]26224824
- Sloan M, Premkumar A, Sheth NP. Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am. 2018;100(17):1455–1460. doi:10.2106/JBJS.17.01617 [CrossRef] PMID:30180053
- Sadoghi P, Liebensteiner M, Agreiter M, Leithner A, Böhler N, Labek G. Revision surgery after total joint arthroplasty: a complication-based analysis using worldwide arthroplasty registers. J Arthroplasty. 2013;28(8):1329–1332. doi:10.1016/j.arth.2013.01.012 [CrossRef] PMID:23602418
- Bansal A, Khatib ON, Zuckerman JD. Revision total joint arthroplasty: the epidemiology of 63,140 cases in New York State. J Arthroplasty. 2014;29(1):23–27. doi:10.1016/j.arth.2013.04.006 [CrossRef] PMID:
- Bozic KJ, Kamath AF, Ong K, et al. Comparative epidemiology of revision arthroplasty: failed THA poses greater clinical and economic burdens than failed TKA. Clin Orthop Relat Res. 2015;473(6):2131–2138. doi:10.1007/s11999-014-4078-8 [CrossRef] PMID:
- Zuurmond RG, van Wijhe W, van Raay JJ, Bulstra SK. High incidence of complications and poor clinical outcome in the operative treatment of periprosthetic femoral fractures: an analysis of 71 cases. Injury. 2010;41(6):629–633. doi:10.1016/j.injury.2010.01.102 [CrossRef] PMID:20236641
- Drew JM, Griffin WL, Odum SM, Van Doren B, Weston BT, Stryker LS. Survivorship after periprosthetic femur fracture: factors affecting outcome. J Arthroplasty. 2016;31(6):1283–1288. doi:10.1016/j.arth.2015.11.038 [CrossRef] PMID:26935943
- Streubel PN. Mortality after periprosthetic femur fractures. J Knee Surg. 2013;26(1):27–30. doi:10.1055/s-0033-1333905 [CrossRef] PMID:23393056
- Lindahl H, Malchau H, Odén A, Garellick G. Risk factors for failure after treatment of a periprosthetic fracture of the femur. J Bone Joint Surg Br. 2006;88(1):26–30. doi:10.1302/0301-620X.88B1.17029 [CrossRef] PMID:
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- Corten K, Vanrykel F, Bellemans J, Frederix PR, Simon JP, Broos PL. An algorithm for the surgical treatment of periprosthetic fractures of the femur around a well-fixed femoral component. J Bone Joint Surg Br. 2009;91(11):1424–1430. doi:10.1302/0301-620X.91B11.22292 [CrossRef] PMID:19880884
- Matharu GS, Pynsent PB, Dunlop DJ, Revell MP. Clinical outcome following surgical intervention for periprosthetic hip fractures at a tertiary referral centre. Hip Int. 2012;22:494–499. doi:10.5301/HIP.2012.9760 [CrossRef]23112076
- Jahng KH, Bas MA, Rodriguez JA, Cooper HJ. Risk factors for wound complications after direct anterior approach hip arthroplasty. J Arthroplasty. 2016;31(11):2583–2587. doi:10.1016/j.arth.2016.04.030 [CrossRef] PMID:27267230
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- Cooper HJ, Bas MA. Closed-incision negative-pressure therapy versus antimicrobial dressings after revision hip and knee surgery: a comparative study. J Arthroplasty. 2016;31(5):1047–1052. doi:10.1016/j.arth.2015.11.010 [CrossRef] PMID:
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| Female||44 (66%)|
| Male||23 (34%)|
|Age, mean (range), y||74 (43–91)|
|Follow-up, mean (range), mo||14 (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%)|
|Parameter||No.||No. of Complications|
|Surgery by fracture type|
| Acetabulum||4 (6%)||1|
| Distal femur||15 (22%)||3|
| Femoral shaft||23 (34%)||6|
| Proximal femur||22 (33%)||5|
| Tibia||3 (4%)||0|
|Surgery by approach|
| Total hip arthroplastya||54 (81%)||14|
| Anterior||5 (7%)||0|
| Lateral||15 (22%)||6|
| Posterior||34 (51%)||8|
| Total knee arthroplastya||13 (19%)||1|
| Medial parapatellar||11 (16%)||0|
| Midvastus||2 (3%)||1|
Univariate Logistic Regression
|Patient Characteristic||Odds Ratioa (95% Confidence Interval)||P|
|Age (continuous)||1.00 (0.95–1.05)||.92|
|American Society of Anesthesiologists classification >2||1.50 (0.47–4.82)||.50|
|Diabetes mellitus||0.39 (0.05–3.42)||.40|
|History of gastric bypass||6.25 (0.94–41.68)||.06|
|Negative-pressure wound therapy||0.07 (0.01–0.58)||.01b|
|Obesity (body mass index >30 kg/m2)||1.26 (0.39–4.10)||.70|
|Peripheral vascular disease||3.68 (1.08–12.53)||.04b|
|Pulmonary disease||5.63 (1.55–20.43)||.01b|
|Smoking history||1.45 (0.25–8.33)||.68|
Multivariate Logistic Regression
|Patient Characteristic||Odds Ratioa (95% Confidence Interval)||P|
|History of gastric bypass||12.02 (1.24–116.71)||.03b|
|Negative-pressure wound therapy||0.04 (0.00–0.49)||.01b|
|Pulmonary disease||11.23 (1.85–68.31)||.01b|
|Peripheral vascular disease||6.84 (1.32–35.39)||.02b|