Background Little is known regarding the occurrence of pneumonia after hip fracture surgery. The purpose of this study is to determine the incidence, risk factors, and clinical implications of pneumonia after surgery for geriatric hip fracture. Methods The American College of Surgeons National Surgical Quality Improvement Program was used to retrospectively study geriatric patients undergoing surgery for hip fracture during 2006-2014. Independent risk factors for developing pneumonia within 30 days of surgery were identified using multivariate regression. Results Of the 29,377 patients meeting inclusion criteria, 13,736 (46.8%) underwent hemiarthroplasty, 9468 (32.2%) intramedullary fixation, 4294 (14.6%) plate and/or screw fixation, 1299 (4.4%) total joint arthroplasty, and 580 (2.0%) percutaneous fixation. In total 1191 patients developed pneumonia, an incidence of 4.1%. The strongest risk factors for pneumonia were male sex, older age (especially ≥90 years), low body mass index, and chronic obstructive pulmonary disease. Patients who developed pneumonia had a higher readmission rate (79.1% vs 8.2%, P Conclusion Pneumonia is a serious complication after geriatric hip fracture surgery, which increases the readmission and mortality risks. Evidence-based pneumonia prevention programs should be implemented among high-risk patients—males, patients ≥90 years, body mass index

Incidence, Risk Factors, and Clinical Implications of Pneumonia After Surgery for Geriatric Hip Fracture.

BACKGROUND: A number of surgical approaches are available for total hip arthroplasty (THA), but there are limited large-volume, multi-surgeon data comparing the rates of early revisions following these approaches. The aim of this study was to compare the rate of revision of primary conventional THA related to surgical approach. METHODS: Data from the Australian Orthopaedic Association National Joint Replacement Registry were analyzed for all patients who had undergone a primary THA for osteoarthritis from January 2015 to December 2018. The primary outcome measure was the cumulative percent revision (CPR) for all causes. Secondary outcome measures were major revision (a revision procedure requiring change of the acetabular and/or femoral component) and revision for specific diagnoses: fracture, component loosening, infection, and dislocation. Age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, femoral head size, and femoral fixation were assessed as potential confounders. RESULTS: There was a total of 122,345 primary conventional THAs for which the surgical approach was recorded in the registry; 65,791 were posterior, 24,468 were lateral, and 32,086 were anterior. There was no difference in the overall CPR among approaches, but the anterior approach was associated with a higher rate of major revisions. There were differences among the approaches with regard to the types of revision. When adjusted for age, sex, ASA score, BMI, femoral head size, and femoral fixation, the anterior approach was associated with a higher rate of femoral complications-i.e., revision for periprosthetic fracture and femoral loosening. There was a lower rate of revision for infection after the anterior approach compared with the posterior approach in the entire period, and compared with the lateral approach in the first 3 months. The posterior approach was associated with a higher rate of revision for dislocation compared with both the anterior and the lateral approach in all time periods. The anterior approach was associated with a lower rate of revision compared with the lateral approach in the first 6 months only. CONCLUSIONS: There was no difference in the overall early CPR among the surgical approaches, but the anterior approach was associated with a higher rate of early major revisions and femoral complications (revisions for periprosthetic fracture and femoral loosening) compared with the posterior and lateral approaches and with a lower rate of dislocation and infection. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early Rate of Revision of Total Hip Arthroplasty Related to Surgical Approach: An Analysis of 122,345 Primary Total Hip Arthroplasties

Background The purpose of this study was to compare the posterior approach (PA) with the direct anterior approach (DAA) among obese and nonobese total hip arthroplasty patients to determine if obese DAA patients have a higher risk of infection or wound complications compared with obese PA patients. Methods We retrospectively evaluated 4651 primary total hip cases performed via anterior approach or PA between 2009 and 2015. Patients were divided into 4 study groups based on approach and body mass index (BMI): (1) DAA Results The rate of deep infection in groups 1 and 3 (nonobese anterior vs posterior) was 0.28% and 0.36%, respectively (P = .783); and in groups 2 and 4 (obese anterior vs posterior) was 2.35% and 2.7%, respectively (P = .80). The rate of wound complications between groups 1 and 3 (nonobese) was 1.0% and 0.3%, respectively (P = .005). Between groups 2 and 4 (obese), the rates of complications were 1.7% and 1.4%, respectively (P = 1.0). There was no difference in reoperation rates for wounds between groups 1 and 3 or between groups 2 and 4 (P = .217, P = .449). Conclusion In the largest available series, there was no difference in deep infection rates between the 2 approaches. In the subset of obese patients with BMI ≥35 kg/m2, there was no increased risk of deep infection or wound complications in DAA patients compared with PA patients. However, anterior hip cases experienced higher rates of superficial wound complications compared with posterior cases across all BMIs.

Comparison of Wound Complications and Deep Infections With Direct Anterior and Posterior Approaches in Obese Hip Arthroplasty Patients

Aims We studied the impact of direct anterior (DA) versus non-anterior (NA) surgical approaches on prosthetic joint infection (PJI), and examined the impact of new perioperative protocols on PJI ra...

2019 Frank Stinchfield Award: A comparison of prosthetic joint infection rates between direct anterior and non-anterior approach total hip arthroplasty.

Background There remains little evidence to support a perioperative hemoglobin A1c (HbA 1c ) level that could serve as a threshold for a significantly increased risk of deep postoperative infection in patients with diabetes mellitus (DM) following total hip arthroplasty (THA). Methods A national administrative database was queried for patients who underwent primary THA with DM. Patients with an HbA 1c level within 3 months of surgery were identified and were stratified based on HbA 1c level in 0.5 mg/dL increments. The incidence of deep infection requiring operative intervention within 1 year for each group was identified and a receiver operating characteristic (ROC) and area under the curve (AUC) analysis was performed to determine a threshold value of the HbA 1c . Results A total of 7736 patients who underwent THA with a perioperative HbA 1c level were included. The rate of infection ranged from 0.7% to 5.9%. The inflection point of the ROC curve corresponded to an HbA 1c level between 7.0 and 7.5 mg/dL ( P  = .001, specificity = 69%, sensitivity = 47%). The AUC for the ROC was 0.68. Patients with an HbA 1c level of 7.5 mg/dL or greater had a significantly higher risk of deep infection compared to patients below this threshold (odds ratio, 2.6; 95% CI, 1.9-3.4; P Conclusion The risk of infection in patients with DM increases as the perioperative HbA 1c increases. However, in the present study, the HbA 1c threshold level calculated demonstrated low discrimination based on our AUC value, suggesting the HbA 1c test is poorly predictive of periprosthetic joint infection following THA in patients with DM.

Is There a Threshold Value of Hemoglobin A1c That Predicts Risk of Infection Following Primary Total Hip Arthroplasty

Background Previous studies have suggested that wound complications may be higher after direct anterior approach (DAA) hip arthroplasty, but, specific risk factors have not been closely examined. Methods We conducted a retrospective case-control study of 651 consecutive DAA hip arthroplasty surgeries performed by 2 surgeons over a 3-year period. Outcome measures included any postoperative wound problem (including prolonged drainage, wound dehiscence, wound necrosis, suture granuloma, and superficial infection) requiring additional intervention or reoperation. Univariate odds ratios (ORs) were calculated, and multivariate logistic regression analysis was performed to determine risk correlation. Receiver operator characteristic (ROC) curves were created to determine disease predictability. Results A total of 75 patients (11.5%) experienced wound complications requiring additional intervention, of which, 13 (1.9%) required reoperation. Multivariate regression analysis found that development of wound complications was significantly and independently associated with body mass index (BMI) 30-35 kg/m 2 (OR 2.05; 95% confidence interval [CI] 1.08-3.88), BMI 35-40 kg/m 2 (OR 3.40; 95% CI 1.42-8.26), BMI > 40 kg/m 2 (OR 7.28; 95% CI 2.55-20.78), and diabetes mellitus (OR 2.97; 95% CI 1.46-6.07). Reoperation for wound complication was significantly associated with BMI > 40 kg/m 2 (OR 5.68; 95% CI 1.17-27.48) and diabetes mellitus (OR 13.08; 95% CI 3.97-43.11). Optimal cutoff values for BMI were found through receiver operator characteristic curve analysis to be 28.0 kg/m 2 for development of wound complications and 28.2 kg/m 2 for reoperation for wound complications. Conclusion Obesity and diabetes mellitus are significantly associated with postoperative wound-healing complications and the need for reoperation for these wound complications after DAA hip arthroplasty.

Risk Factors for Wound Complications After Direct Anterior Approach Hip Arthroplasty

The mini-anterior approach: Optimizes total hip arthroplasty outcome—Affirms

Background: Although total hip arthroplasty (THA) performed through the direct anterior (DA) approach is frequently marketed as superior to other approaches, there are concerns about increased risks of intraoperative and early postoperative femoral fracture. Purpose: We sought to assess patient-specific and radiographic risk factors for intraoperative and early postoperative (90-day) periprosthetic femoral fracture (PPFx) following DA approach THA. Methods: We retrospectively reviewed 1107 consecutive, primary, non-cemented DA THAs, performed between April 2009 and January 2015, for intraoperative and early postoperative PPFx. Patients lost to follow-up before 90 days (63), cemented or hybrid THA (52), or early femoral failure for another indication (3) were excluded, yielding 989 hips for analysis. Demographic variables and patient comorbidities were analyzed as risk factors for PPFx. Continuous variables were initially compared with 1-way analysis of variance (ANOVA) and categorical variables with chi-square test. A demographic matched-paired radiographic analysis was performed for femoral stem canal fill and compared using univariate logistic regression. Results: The incidence of perioperative PPFx was 2.02%, including 10 intraoperative and 10 early postoperative fractures. Sustaining a postoperative PPFx was associated with being 70 years old or older with a body mass index (BMI) of less than 25, or with having either osteoporosis or Parkinson disease. Radiographs demonstrated that intraoperative PPFx was associated with stems that filled greater proximally rather than distally. Conclusion: Our cohort study found older age, age over 70 with BMI of less than 25, osteoporosis, and Parkinson disease were associated with increased risk for early postoperative PPFx following DA approach THA. Intraoperative fractures may occur with disproportionate proximal femoral canal fill. Further study can evaluate whether cemented femoral components may mitigate risk in these patient populations.

Kenneth H. Jahng

Papers

Risk Factors for Wound Complications After Direct Anterior Approach Hip Arthroplasty

The mini-anterior approach: Optimizes total hip arthroplasty outcome—Affirms

Risk Factors for Periprosthetic Femoral Fracture in Non-cemented Total Hip Arthroplasty Through the Direct Anterior Approach